R-41034b
OFFICE COPY
PERMIT
R- 410 3
APPLICATION FOR CITY OF CUPERTINO NUMBER
sk INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
XPIR180 SIFYS WORK
(408)252-4505 EXT. 228 PERMIT EXPIRESO KIS NOT STARTED
WITH OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
A , 'PnE
X30,!5 — A/
6 4-4- ('.IJ
-
RESIDENTIAL COMMERCIAL OTHER
,OWNER'S
AN,i
HAZARDOUS ROOF
NAME " ""a""
FIRE COVERING
ADDRESS I %tL
AREA CLASS
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE �a [ (o Q
CONTRACTO S ,
��^ n Un .^.J �/OD�i �r•
TO BE REMOVED TO BE RETAINED
TYPE F ROOF COVERING
cor
NAME - ���7II /,/ CCw HL�(/o(i/tY/1 , `
r'7�
CDY&Zia
EXISTING
BUILT-UP ROOF
PHONE--( ri�_%�'�6
_i
LICENSE LJ/ _ /. P7
AS ES
NUMBER 53 rCJ
OD SHAKES
L I CENSED CONTRACTORS DECLARATION
1 hereby affirm that I em licensed under provisions of Chapter 9 (common
Gino with Section 7000) Of Divi.ian 3 of the BOsinas. and Prof ... ion, Code,
SHINGLES
and my license is In full force and affect.
License Class Lic. Number
Data Contractor
OTHER (SPECIFY)
OWNER -BUILDER DECLARATION
I hereby affirm that I em ... mat from the Conpamar i Licama Law for
PROPOSED
the following reason. (Sac. 7031.5, Business and Professions Code: Any city
orcounty whichrequiresa permit to construct, alter, improve, domolish,or
repair any structure, prior to its issuance, also requires the applicant for such
BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
Fill Division 3 of the Business and Professions Code) or that he is exempt there
ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permitubjects the applicant t0 a Civil penalty
of not more that five hundred dollar ($500).):
WOOD SHAKES
I] I, as owner of the property, or my employees with wages as their fOle
compensation, will do the work, and the structure is not intended or offered
for sale (Sec. 7044, Business and Professions Code: The Contractor's License
WOOD SHINGLES
and who eons such workhimself ownerr improve, ded that
Lew doss not apply too an owner of property who b employees,
or through g^ his own employee., provided that
such improvements are not intended o offor sale. If, however, the
cone
OTHER (SPECIFY)
ui:din, or improvement is +old with, veer of completion, the owner
builder will have the burden of proving that he did not build or improve for
Purposeoo.ale.).PROVIDE
I.C.B.O. REPORT NO.
O I, s Owner of the property, am exclusively contracting with licensed
contrac fors t0 construct the project (Sec. 7044, Business and Professions
Code: Th. Cont,actor'+ License Low does no, apply to an owner of property
PROVIDE III INSTALLATION SPECS.
who builds or improves t^eraun, and who contracts for such projects with a
contrctor(s) licensed purwem to the Contractor's License Law.
p em exempt antl.. sac. ,0.6P.D. for this uson
APPLICATION DATE
VALUATION
PERMIT FEE
Own. r Data
-
WORKERS'COMPENSATIONDECLARATION
Building/a
I hereby affirm that I have a certificate of consent to self insure, or a car
[ilic 'a of Workers'Compensation Insurance, or a certified copy thereof IS...
I
38IamiD
3800, Lab. C.I.
Policy No. Company
M /�`�
8 Certified copy is hied w furnished.
Certified copy is filed with rhe city inspection division.
'JUS ^2
1•' 0 5L,
v J./
Total
Applicant
MY Iqc
PERMIT A THO IZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'^.
NC• El
COMPENSATION INSURANCE
(This +action need not be completed if the permit is for one hundred dol
lar. ($100) a, les..)
rbc
1 certify tbe, in me performance of the work for which this permit is
issued, 1 shall not employ any person in any morn., 1P es to become subject
t0 the Walk.,. Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: 11, eine making this Certiliute of Exemption,
you Should become subject to the Workers' Compensation provision. the
Lobar Coda, you must forthwith comply with such provision, or oris permit
All roofs be inspected roofing material being
mall be deemed r•.ok•d.
prior
P D Y g g
I comfy that 1 have read this application and state that the above inform..
Installed If a roof is installed without first Obtaining an
tion is correct. 1 agree to comply with all city and county oraln.n<.. and
pure law. relating t0 building construction, and hereby authorise rpraseo-
inspe ion yea to 11 starlets for Inspection.
P
PI
tatives of this city to anter upon the above mentioned property for Inspection
�V/f/(VV///�
/,/�k.(•itrV��•i
Purposes
(Wt agree sive, indemnify antl kap hermlass me City of Cupertino
we)
against liabilities, judgments, cents and expenses which may in any way accrue
SIGNATURE OF APPLICANT DATE
saidiyi cons
against said City in consequence of the granting m this permit.
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