R-4189 PERMIT
APPLICATION FOR CITY OF CUPERTINO INUMBERR-as 4189
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYSOF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
1990 BeG L 1`In Gh 1 P ICe RESIDENTl COMMERCIAL OTHER
OWNER'S
HAZARDOUSO ROOF
NAME GM CA I FIRE COVERING
AREA CLASS
ADDRESS Iq l l l CeI<MClkl C1CC— EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS /
PHONE
CONTRACTOR'S —Co (� r
Less 1,001 TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
CDD BEZSP Pro. Bmc X11863L. A 9 C5811 EXISTING
PHONE alb _4jc 8859 BUILT-UP ROOF
LICENSE 3g 3 2 b g ASPHALT SHINGLES
NUMBER J
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 WithhereS ction 7000 I of licensed near provisions of Chapter s o 0 Code,
<ing wi<0 Section 70001 of Division 3 of the Business and Pro+...ions cod., WOOD SHINGLES
and my license Ie In sell and effect.
License lap Lin.Numbs
Da. Connacto. 328 OTHER (SPECIFY)
IO �.'
OWNER BUILDER DECLARATN
I hereby affirm that I am exempt from the Contractor's License Lew for PROPOSED
the following reason. (Sec. 7031.8, Business and Professions Coda: Any city
ar county which requires a permit to construct, alter, improve,dem Oli+h,0r
repeh any structure.prior to its issuance.also requires the applicant for such BUILT-UP ROOF
oermit to fila a signed statement that he is licensed pursuant to the provisions
of the Contract3.fo:s License Law (Chapter Professions (commencing with Section I7000)
n...
fr Division 3 of the Bfor theand nd .. ti.h. or that oa is exempt mo.' ASPHALT SHINGLES
from and the bast+ for the apermi aaempt In Any violation of Section
.1 not by any tfive hM tar a permit subjects[M1a applicant t0 a civil penalty
ai not mon that r of hundred dowers r my e.l: WOOD SHAKES
❑ I,n owner of he p.operly, or my employees with wages as mair sola
compemation,will do the work, ane the structure is not intended or offeree WOOD SHINGLES
for sale (Sac. 7044, Business and Professions Code: The Contractor's License
Law don not apply to an Owner 01 properly who builds or improves Ina/eon,
antl whimo does such work himself or through his own employees,provided that / NG.!/ f
such provements • m r
nintended o offered for sale. If, however, She OTHER (SPECIFY) r tris Y
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving[M1a[he did nes[build or improve for
purpos..f s.l..l. PROVIDE I.C.B.O. REPORT NO.
❑ l. . of the property. am exclusively contracting with licensed
convectors to construct the project (Sec. 7044, Business and Professions
Code: The Contractors License Lew does not apply to an owner of properly PROVIDE MFG R. INSTALLATION SPECS.
who builds o improves thefoun, and who connects for such projects with e
contractor(s)Ii tamed pursuant to me Contractor's License Lew.
c CII am exempt under Sac. ,BAP.C.I.,this
reason PPLICATIO DAT q EVALUATION PER T FEE
owner
ffin
WORKERS'COMPENSATION DECLARATION C/Care— fall v BUIldin
1 hereby affirm that I neva a certificate of consent to self insure,or a car �Y �i
tilicata of Workers'Compensation Insurance,or a certified cagy thereof ISec. ��, 19 seismic
3800,Lab.CA C / / Y / 1700
Policy No.l3Q]StYS Company dTa.--f, P,. r1 V'
C.rif ocopy +In It +uMn; !it Cy ✓\ �-�/ Total
cerabea cop hied t the city in coon division.
Applicant , ....
CER ATE Of EXEMPTION ROM WORKERS' NC 0 PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This+action need not be completed if the permit is for one hurt Nd 001
tan 15100)or Iess.l r7
1 certify dist in the performance of the work for which this permit is L 11
Issued,
I shell n
not employ any person in any manner so as to become su bjact
to me Workers'Compensation Laws of California,
DZ T____
Applicant
NOTICE TO APPLICANT: If, atter making this Certificate of Exemption.
You should become subject t0 the Worked Compensation provision+of the
Labor Code, you must forthwith comply with such provisions or this permit All roofs shall be inspected prior to any roofing material being
Mail be deemed revoked.
I certify that I have reed this application and state that the above informs. installed. If a roof is installed WlthoUt first obtaining an
tion i, correct. I .g... to comply with .n hints and npppW q.ein.nn..and inspectio I agree to remove I new materielsforinspectiort
un laws Icing to building construction, and hereby authorize rsOresam
lativw of this city to enter upon the above mention"property for inspection
Purposes. .-S ` S
IW. e �
prse to save, indemnify and keep harmless City of Cupertino 'of n// d
against liabilities,judgments,costs and expenses which may in any way accrue w w" i
against gid City In consequence of the granting of this Permit. SI NATURE 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