R-4146 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4146
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS(,408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT NOT
OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
Lo �� • �� RESIDENTIAL COMMERCIAL OTHER
OWNER'S
I/ ) G HAZARDOUS ROOF
NAMEG//�� RE COVER
AREA CLASS ING
ADDRESSJD/lli BJI-IcH EXISTING ROOF COVERING
PHONE Q — 71'9
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S n /
NAME CAEC-11— T. /'( [[Y�15.0 TO BE REMOVED TO BE RETAINED
TYPEOF ROOF COVERING
YSs
CITaZ1#141 Uek
EXISTING
CG[ "rl,A/O 4SOiy
PHONE 2,s�sr I C, g —2 i G BUILT-UP ROOF
LICENSES, ` ASPHALT SHINGLES
NUMBER2- 7
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(common.
Sing with Section TOM) of Division 3 of the Stinnes.and Prof.. Cold WOOD SHINGLES
and my license is License ss fyylI y�l{ ifect. {�
Cla6`e' rJ 1tle Lic.Numbs
Data DeContractor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am..amp, from the Contractor's License Lew for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
Or county which r.auires a permit toe nseruet, S., improve, demalith,or
repair env structure,prior to its issuance .I..requires the applicant for such BUILT-UP ROOF
permit to file a signed 11.1...m roes he is licensed pursuant to the provisions
of the Contuctoi• License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions code)or me
et he is e. mot tn... ASPHALT SHINGLES
bons an ma hurt for ma alleged exemption. Any violation rr section
7031.5 by any applicant for a permit subjects the applicant 10 a evil penally a
of not more that hve hundred dollar,(9500)1: WOOD SHAKES
❑ I, as owner of me property, or my employees with wages as their sale
comp....thin,
omp....thin,will do the work, and the Structure is not intended 0,offered WOOD SHINGLES
for eab(Sec. 7044, Business and Profession.Code: The Convector'.License
Law does not apply to an owner of property who builds or improves thereon,
and who does such work himself or through his own employees,Provided that
Such improvements are not intended or
offered for Sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the a
builder will have the burden of proving mat he did not build or mprove far
purposeof sale.). PROVIDE I.C.B.O. REPORT NO.
C) I, at owner of the property, am exclusively contracting with licensed
con Vac tort to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property PROVIDE III INSTALLATION SPECS.
who builda, or improves protean, and who contracts for such Projects With a
con,rector(.)licensed pursuant to the Contractor'.License Law.
❑ 1 am ...mat under Sec. ,B.&P.C.for this
r...on APPLICATION DATE VALUATION PERMIT FEE
Owner Date
WORKERS'COMPENSATION DECLARATION Buildenb"..xt
I hereby affirm that I have a certificate of consent to self-insure,o
tificato at Workers'Compensation Insurance,or a certified copy thereof(Sec. r� Seismic
3800,Lab.C.). ILy p
Policy No. Company PA
6 Certified copy is hereby furnished. o Total
Certified copy is filed with me city inspection division. 17 6g
Applicant LU If Six
CERTIFICATE OF EXEMPTION FROM WORKERS' N D ❑ '1y J RMIT AUTHORIZATION DATE
COMPENSATION INSURANCE // i1
(This sootiest nNtl not be completed it the permit it for one hundred dol. I I h 1/
IeN($ero)or her i I.UH�H(fNp YV/
1 u.efv her in me pam.meape of me week lir which this permit i,
issued, 1 .hall not employ any person in any manner.o as to became subject
to the Workeri Comp.neasion Laws of Callfornie�n
Delo Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you should become subject to the Workers'Compensation provisions 01 the
Labor Code.you must forthwith comply with such provisions or this permit
Shan be domed evoked.
All roofs shall be inspected prior toany roofing material being
r
Icertify the, I have read this application end let.the,the above inform.. installed If a roof is installed without first obtaining an
tion is carrots. I agree to comply with all city and county ordinance.and Inspects agree to remove all new materials for inspection.
Puts laws relating to building construction, and hereby autnorin roresem —�_
utives of this city to enter upon me*have mentioned property for i
peansp ¢tion 6Y
) /// /we
IW. agm s, live, indemnify and keep eermbes m• City ai ay cc u.
against said liabilities,i judgments,creta and expense.which may in any way accrue
ewmn said City in consciousness of me granting of this Dermic ATURE OFAPPLICANT 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