R-3844 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Res 3844
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT.228 WITHIN 1W DAYS OF WORK IS
OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS O�L{ (K�Q,,,yfl,O �( BUILDING USE
1 O 10I � I O� 1 I [1,1�'V' �""� �� RESIDENTIALX__ COMMERCIAL OTHER
OWNER'S
i � HAZARDOUS ROOF
NAME ✓^11Y�( A A-�I OIWt�O FIRE COVERING
AREA CLASS
/�W1S �5��) 1n✓ 1 EXISTING ROOF COVERING
r
PHONE 08 86 /J ` v NUMBER OF EXISTING COVERINGS i
CONTRACTOR'S (� .[�,,, 1
Or` r�DO\ "' TO BE REMOVED f TO BE RETAINED
NAME
TYPE OF ROOF COVERING
ADDRESS ��77
CITY&Zl/h' f7- S �3" Sar EXISTING
PHONE I�'1 7iBUILT-UP ROOF
LICENSE 7aCa�10 ASPHALT SHINGLES
NUMBER -IJJ
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 hereby affirm O I of Division
unser provisions of Charter 9(common.
and y li lSea icense
.n )000)once
Division 3 of Me Business and Profaesi n.cps.. WOOD SHINGLES
end my Ilunu 1 I force ens affect.
LlosIse Lic.Number
Da.ns contractor OTHER (SPECIFY)
OWNER-BUILDER DECLARATIO
I hereby affirm that I em ax.,P, from the Contractor's Litems Lew for PROPOSED
the following reason. (Sac. 7031.5. Business and Professions Cooe: Any city
or county which requires a permit to construct, after, Improve,demolish,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 Licem. Lew (Chapter 9 (commencing with Section 7000) P A I D
oI Division 3 of the Business and Professions Code)or that he is exempt there ASPHALT SHINGLES
from and the beds for the alleged exemption. Any violation of Section
7031.5 by any applicant re a permit subjects the applicant to a civil penalty MAR 15
oI not 1,as own.,
of hundred .or myoz): WOOD SHAKES MAR
❑ I,es ownv pf the work,a or he employees with wages as f Offered cpm ale (See,
will do Ts work,end the structure is not im.nrao or Li ease
for.aa (sec. ]044, easiness and f property who The or improves
Licence WOOD SHINGLES
Law what not apply to an owner of property who builds or improves provided
that CI,I
and uc who doe such work himself or through his o malle. It, provider fhet
such ng or improv are
not incenses or one
year
for sola. It, however, ma OTHER (SPECIFY)
building or improvement I. bur if sola within glia year o/completion, p owner
builtlar will have Te burden of proving[M1u he rid not build or improve Ihr
Pump"
of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I. as owner of the property, am exclusively contracting with licensed
con[recton to construct me project (Sec. 7044, Business and Professihm
Cada TheContraces n
foisLicenseLowdoesnotapplytoanownerofproperty PROVIDEMFGR. INSTALLATIONSPECS.
who b.Id i improvmaun, and who contracts for such projects with e
contractor($)licensed Pursuant to the Contractor's License Lew.
p 1 am exempt ghee. S.T. ,B.aP.c.foe this APPLICATION DATE VALUATION PERMIT FEE
oD.r.
Own. WORKERS'COMPENSATION DECLARATION Building
1 hereby affirm that I have a certificate of consent to self insure,or a car �n✓ (T'—F
3800te of Workers' Compensation Ind nu,o.a ceadietl opy Thereof(Sac. Seismic t�d
3800,Lab�l.1 l /] yUn ` /
POIIcY No. kk 0f �n_4Ccmdeny �j/�
tE Certified copy I.her y 11 roil a Total l q w
Q'Caair, copy 'lea it ma I"[ �nfpaction aiviaion.
Applicant
CERTIFICATE OF EXEMPTIO FROM WOR Rs' N C PERMIT AUTHORIZATION DATE
COMPENSATION ON IN URANCE
(This section need not be comple[ea'il the per t is for One hunrred I
lays($100)pr less.)
cortilY toot m the Par'_
of t work for ch Tis p mit 1
in ed, I shall not employ any pan on y manner[ ' 'O bec0 ubj« �• 1/v�0 ��
to[ha Worbri Compensation L ,Cailornia. Vim.
Date A ant
NOTICE TO APPLICANT. If, after making th is tof tion,
you should become subject the Workari Com a vor�I�vionf o1 th
Labor Code, you must for[hW comply with .0 not this Per [ All roofsshall be inspected prior to any roofing materialbeing
•hen be d«mew revoked.
[[ installed If a roof is Installed without first obtainingan
1 certify that I nave rend this• lic•t s[I Tth.above ins ruse
;ion is pdr;e t. I .g.« To chmP1 with nI v a ntv drdin.n s dna insp coon,I agree to rem ve all new materialsforinspection.
uta laws lacing t0 building Cons ti w M1are Y authorize r Pmm
tetives of this city to enter upon the ore n 'dead property for i spaction l
(We) •gree to me, in0amnify end k«p h Ins Ta City o Cupertino
against liabilities,judgmenn,costs and comes which may In an w•Y accrw
•gaunt sola city in consequence of the gr ming of this permit. SIGNATURE OF APPLICANY DATE
PRE-INSPECTION: PLYII D: IN-PROGRESS:
INSP. DATE INSP. DATE INSP- DATE
TEAR OFF INSPECTION: ENS: FINAL
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY .