R-4118•
•
•
OFFICE COPY
PERMIT R- 4118
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYSOF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS '^^ (,
- BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'SROOF
HAZARDOUS
NAME O �1,
FIRE COVERING
CLASS
EXISTING ROOF COVERING
�Sv�(,�,
�Q �,
L D
/
ADDRESS�-+'v y I,(.I f
I U
(!��-f
S—
NUMBER OF EXISTING COVERINGS 1
PHONE 1.
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
NAME
4
nn (� ,, O
N
CIORESS
TOY a 21h tell 1 -�z7` /-,isle
EXISTING
7
KJ
BUILT-UP ROOF
PHONE �LiI� --(i
ASPHALT SHINGLES
LICENSE�y o
NUMBER q
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter 9
o
WOOD SHINGLES
ting with Section )0001 i Division 3 of [M Business and Prof es cot:.
and my licanse I '� fu. a end affect.
O- •�-a%
License Cie. Lic. Number
OTHER
Det. AC.ntract.,
(SPECIFY)
C,*t&6W&E!R%U11LDERDECLARAT O
I herby affirm that I am exempt from the Contractor's License Lew for
PROPOSED
me lollowing reason. (sort. 7031.5, Business and Professions Code: Any city
or county which requires a permit to construct, alter, improve, demolish,or
repair any structure. prior to it issuance, also requires the applicant for such
BUILT-UP ROOF
permit to fl la a signed statement that he is licensed pursuant to the provisions
q1 the Contractoi • License law (Chepter 9 (commencing with Section 70001
of Divisi0, 3 of the Business and Professions Coda) or that he i, exempt there'
ASPHALT SHINGLES "
from and the basis for the alleged exemption, Any violetionof Section
903116 by any applicant for a permit subjects the applicant to a civil penalty
of not more that live hundred dollars lss0 1:
WOOD SHAKES
❑ 1, as owner of the property, or my a loyee. with w es [Heir sola
compensation, will do the work, andma m. .re i. not in or oueree
aPWn'..,
Tor seta (Sac. 7044. Business e)W e: line Co v t '. License
WOOD SHINGLES
Lew does not apply to an ow r'pbuittls ori s thereon.
and who do" such work himself orw plo as, idea that
improvements are not intenIf, hvW...rthe
OTHER (SPECIFY)
buch
ilding .r improvement I. sold wf O plaNOn, the owner
Guilder will have me burden oI rid uild or improve for
purposefsole1
❑ 1, a. own.. 1 tna o y, lutively cOntretting with li[wn.atl
contractor to con c Drojac ac ) 44, Business and Profession
code: me Conlrec �•. - e . La- I PIP To an owner of property
PROVIDE I.C.B.O. REPORT NO.
PROVIDE III INSTALLATION SPECS.
Who builds or imp' Braun, and M1 Contract. for such projects with e
contract., lel lice d uant to the Contractor's License Lew.
C3 .m exempt . 6 sec. ,B.aP.c. to, mi'
".aeon
APPLICATION DATE
VALUATION
PERMIT FEE
heli
OviDem
WORKERS' COMPENSATION DECLARATION
�����
Building /S6.�
1 neraby affirm that I have certificate of consent to .eDimure, or a can
V
tific '. of Worker" Compense Insurance or a certified copy thereof (Sec.
3800, Lab. 1-''1`,�^
C
)
$ei$mIC /60
Policy No. � LtlriPeny
8 Corti ad copy is hereby furp:m P.
Total �fs7 G"o
Caaifie op i. file with a iter insD n n div,
Applicant
AUTHORIZATION
DATE
c IFICATE o x P F WORKERS' N.C.
COMPENSATI O NINSURANCE C ElPERMIT
�^
ITnis section need not be completed if the permit is for one hundred dol
ler. 151001 or Ioll
3
1 certify that in the performance of the work for which this permit is
issued, I shall not employ any personany manner so as to become subject
to the Worker" Compensation Law. 01 Cslif.rni., n
�• �^-
0� N/wU�F
Deer Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you should become subject to the Worker" Compensation provisions of the
Lobo, code, you must forthwith comply with such provisions or this permit
All roofs shell be Inspected prior to any roofing material being
sh.11 be deemed revoked.
I certify mm
at I have rand his application and mat me above info,s
installed If a roof is installed without first obtaining an
ti.n i. correct. l agree to Comply with all city and county ordinances and
aterialsforins ectio
Inspection, I a ree to remove all ne n
P g P
Iota Is. Ling 10 building construction. and hereby .uthoriZe rpresen.
to ives of this cry to enter coon the above mentimad property I., inspection
P.'POees.
(W.) spree to save, indemnify and keep harmless the City of Cupertino
. ff
against liabilities, judgments, costs and expanses which may In any way accrue
&wino said City in consequence of me this
S N TORE O
v
APPLICANT- ` CATE
granting of Permit.
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS:
AUGVV
INSP. DATE
INSP. DATE
GI EIJJ995
INSP.
TEAR OFF INSPECTION:
BATTENS:
FINAL: (;I I Y Ur LW:H I INU
INSP. DATE
INSP. DATE
INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY