R-3983 PERMIT
APPLICATION FOR
CITY OF CUPERTINO NUMB R Res 3983
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)252-4505 EXT. 228 WITHIN 180 DAPERMIT VSOF PERMIIF WORK T ISSUNOT AN ED ETOR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �%,Q �/�/ BUILDING USE
U t-C" " A`^' - RESIDENTIAL 0& COMMERCIAL OTHER
WER'S/
/ (((/hO (//` HAZARDOUS ROOF
NAME FAIRREEA CLAASESRING
ADDRESSTv �<//�/C EXISTING ROOF COVERING
L-{/
PHONE NUMBER F EXIS COVERINGS
CONTRA DR'S
J /ti/� �' / . TO BER MOVED TO RETAINED
NAME W !� TYP F OF CO 6RING
ADDRESS
CITY&ZIP YV CmEXI ING 011Q
PHONE /1 3/4,/
J ! �LZ ILT-U F l V
LICENSE ��� ASPHALT S GLES
NUMBER 6 WOODSH
LICENSED CONTRACTORS DECLARATION
I net.by affirm that I em licenseo nein,in,li ions of Chapter 9(common
mg with.n tion 7000) of add affect
3 of the Business maw WOOD SH LE
.red m i license b x700 antl affect.
upon..Arl Lic.Number HER ( Y) &R 27 19
bats 95
'd Contr«tor
��/ OWNS ERi•BUILDER DECLARATION �III�U
, hereby affirm that I am exempt from the Contractor'. License Law for Uf vJYC
the following reason. (Set. 7031.5, Busing«and Profession.Come: Any city PROPOSE Ill
or county which requires a permit to construct, altom
, improve,deulish,or
repair any structure,prior to its issuance,also requires the applicant for such BUILT-UP RO
permit to fila a signed statement that he is licensed pursuant to the provisions y)�
of the Contractor'. License Law (Chapter 9 (commencing with Section 700o) ! 0 b /9.
of Division 3 of the Business and Professions Coda)or that he is exempt there ASPHALT SHINGLES
•
from antl the bops for the allege. exemption. Any ant to
of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more that five the pro saran r my e.1: WOOD SHAKES
I.
as
owner of me proork, a o he employees with wanes as r air hilt
compensation,will do she work, Profess structureCodis not intended or License WOOD SHINGLES
far gala (Sac. 7044, Burmese andnen Professions Property
Code: The Comimo.s'+License
Lew a0«not apply toe of of hr o gh is o build.employees,
!i es, Oves dept that
sanduch
who iroai such work himself or through offered fif employee+, howl ver that
uil ng or improve ere not antededwith a neya for +n.. u, nothexme OTHER (SPECIFY(
building or have t improvement is sola Proving
fin a year of completion, the owner
builder will nrva dna burden of proving leel he Pia not build or improve fhr
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
0 I, as owner of the property, am exclusively contracting with licensed
Contrac toto construct ma pject (Sec. 7044, Business and Professions
Coda: TheContracmisLicemeroLawdoesnodapplytoanownerofProperty PROVIDE MFGR. INSTALLATION SPECS.
who builds Of improves theraun,and who contracts for such projects with a
contractors)licensed pursuant to the Contractor's License Law.
p Ism exempt unser sac. ,B.aP.c.for his
reason APPLICATION DATE VALUATION PERMIT FEE
Ow 0«e
Owner WORKERS'COMPENSATION DECLARATION /-� Building %_ 00
I hereby affirm that I nava a certificate of t to If insure,or a can o
tificrte of Workers' ampan iddirt Imur; ys+he Coy thereof(Sec. �//Yv Seismic $640
Poll Leb.C.Is/f�� {!^,( _ I f
Poll N�./,_lfcop,. h Company 1777//C 4D
C aieo opy d+h eby furnianed. Total
Cenifjep�apv' d W.In
In.city inspection division.
Applicant 1
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
D ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one huntlfed PCI.
Ian(51001 or I...)
1 certify m« in me performance of me work for which this permit i+ a
issued, I mall not employ any person in any manner so as to become sublet[
1h me Workers'Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, atter making this Certificate of Exemption,
you shod to become subject 10 In.Workeri Compensation provisions of the
Labor code, you must forthwith Comply with such provisions or this permit
shall be deemed retoketl. All roofs shall be inspected prlOrto any rooting material being
I certify that I have read this application and state that the above informs Installed If a roof Is Installed without first obtaining an
lion is conett. 1 agree to comply With ell city and county ordinances and IRapeCtlO �lB� !e oveall new material tint Ins ectl0n.
state laws relating to building construction, and hereby authorite .or...n
datives of this city to enter upon the above mentioned property for inspection `��
Purposes, l
(We) .ores to eava, indemnify and keep brimless the City Cf Cupertino
against liabilities,judgments,costs and expenses which may in any way accrue
against said City in consequence of the pnnHnp of this permit "ATURIE OF APPLICANT DATE
• 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