R-4184,40
M
OFFICE COPY
PERMIT 418 4
INUMBERRas
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT PMIT EXPIRES NOT
IF WRK IS STARTED
(406)-252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
- BUILDING USE
n/ tl
C—_ �2
/00/0
v
x
JAI
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
L`
�"
HAZARDOUS ROOF
NAME _'
FIRE � COVERING
AREA CLASS
"f C
EXISTING ROOF COVERING
ADDRESS r
p
$z
NUMBER OF EXISTING COVERINGS /
PHONE
CTOJ�'S
, �
r �
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
EXISTING (
NAME /(�1 -� 0O /
NAME—
ADDRESS c) 1801( `)(D3 C44-1 /0
2�p S -,-/ (4 7
BUILT -UP ROOF
PHONE
LICENSE ���
ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS no RS DEOLARATION
I herabV affirm roar I am licensed unOer provisions or DnaD,er 9 (common
$
tiny wain section 7000) f Division J of the .wines ana Pr fxiJon Coda.
WOOD SHINGLES eQfT•••
n
and my Ilcen- eA Juf6 e enact. '1 �/�
Liven Ian t`. JJ Lie. Number Or lJ
oats -�= Connector
OTHER (SPECIFY)
OWNER- BUILDER DECLARA ION
I herby affirm that 1 am exempt from the Contractor's License Law for
PROPOSED
the following reason. (Sec. 7031.5, Business end Professions Code: Any city
1 .
Or county which requires a permit to construct, alter, improve, aemoli.h,Or
repair any structure, prior to its issuance, atf requires th• eDPl;c..t for such
'Ay`
BUILT -UP ROOF
perm❑ to ills a signed statement that hares Iic need pursuant to the provision
of the Contractor's License Lew (Cho r 9 mmencing vi th S n 70001
x
01 Division 3 of the Business and Prof., deal or the, he empt there
ASPHALT SHINGLES
from and ire bash the ells d e t n. Any vi of Section
]OJl.6 by soy app it jacta the a lice a vii penalty
I ndi more the rly. ssool.):
WOOD SHAKES
❑ I, as owner ry, or m ploys F th we o as mair sole
companastion, wall one th t tyro Ot intened oroilereC
for sae (So. 7004, Prof aid Cdd a Convector s License Law do. not apply of pro a o builds or improves thereon,
yV00D SHINGLES
and who does such Or th, h his own employee., provided that
such improvements • not intended or offered for sale. If, however, the
OTHER (SPECIFY)
buad;ng o mprovam n, I. ..to within one year of completion, the owner.
builder will have the burden of proving that he did not build or improve for
purpo'° of sale.).
PROVIDE I.C.B.O. REPORT NO.
C3 1, as owner of the property, a exclusively contracting with licensed
tomtit tors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor. License Law doe, net apply id an owner of property
PROVIDE III INSTALLATION SPECS.
who build' or improves thereun, and who contracts for such projects with a
Contractor(') licensed pursuant t0 the Contractor's License LBW.
so1 am e.empt dose. sae. ,B.aP.c. for this
reason
APPLICATION DATE
VALUATION
PERMIT FEE
Owner Date
WORKERS' COMPENSATION DECLARATION
Building
I hereby affirm that 1 have a certificate o1 consent to self-insure, o can
/j��
tii'p:ar Of WOrkeri C Densation Insurance, or Car fied coo misr df B.e.
JB00, Lab //LL��..�� (u�/)Y -}�`}L /,I)
L.1, I?
/'j /l
p
pelamiCi
rlo
Policy SOmpeny `T/ �T -/ `sees'
C.rtiNed top by fwnieii.d.
l/1{
Total
Cartiila�wf4 -o y I -ih the ih^.pacdon division.
'chnY
Applicant iA I 'a /1 r✓bL`� '
PERMIT AUTHORIZATION
DATE
TIF ATE OF EXEMPTION FROM WORKERS' N.C. ❑
COMPENSATION N S URANCE
(This section need not be completed if the permit is for one hundred dol.
Ian ($100) or Ins.)
1 certify that in the performance of the work for which this permit is
su ad. I shell not employ any person in any manner to as to become'ubj «t
to 1M Workers' Compensation Laws of California.
Da- Applicant
NOTICE TO APPLICANT: Ii, Biter making this Certificate of Exemption,
You should become subject to the Workers' Compensation provisions of the
Labor cdee, you most forthwith damply With Such provisions or this permit
All roofsshall be inspected prior to any roofing material being
shall be deemed revoked.
I ca"ify that I nave nee ml' eppliuuon ana ruts that tna above Inbrme.
Installed, If a roof Is Installed without first obtaining an
tldn is sour «L I .gr— to eomply with .n city and county ordinances and
inspection, I agree to remove all new materials for inspection.
sot. law. reefing to building construction, and hereby authorise rapresee
etives of this city to enter upon the abOVemartioned property for inspection
Purposes. '
vi l agree to save, indemnify end keep harmless the City of Cupertino
against liabilities, judgments. Gotts and expense. which may in any way accrue
against said City in consequence of the granting of this permit.
SIGNATURE OF APPLICANT DATE
I, PRE - INSPECTION:
PLYWOOD:
IN- PROGRESS:
INSP. DATE
INSP. DATE
INSP. DATE
TEAR OFF INSPECTION:
BATTENS:
FINAL:
INSP. DATE
INSP. DATE
INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY