R-4045L
OFFICE COPY
Rife
PERMIT 4045
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMITNOT STARTED
WITHIN 180 DAYSOF PERM EXPIRES IF WORK IS T ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
�
. •�j/O _//��(J .Q�
y(
RESIDENTIAL—,&— COMMERCIAL OTHER
OWNER'S
NAME /� ( `
HAZARDOUS ROOF
FIRE COVERING
AREA _ CLASS
`j
EXISTING ROOF COVERING
ADDRESS 0�7a
/ /
PHONE \ QOp � 114e o - d
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
CONTRACTOI
l
NAME
'rte
TYPE OF ROOF COVERING
�tiV
CIT &ZIP W1a 1
EXISTING
rrJ•.�s't�y i�
/��"7> a
PHONE</"7> S � �t _ Fl tto
BUILT-UP ROOF
ASPHALT SHINGL r
LICENSEq/ �/
�-
NUMBER O (r� � 7f
WOOD SHA S
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g (common-
cin, with Section 7000) of Diviai.n 3 of the Business and P1. enlons pCode,
IItems Is In syn tl bU
WOOD SH INCL S
and my o an affect.
L.' Number
/
Ll..m. Cly Li.
Det. / Contract. N
OTHER (SPECIFY)
OWNER BUILDER DECLARATI N
I hereby affirm that 1 am exempt from the Contfac[o: f icons. Lew for
PROPOSED
the following reason. (Sec. 7031.5, Business and Profession. Code: Any city
or county which raouir.s if permit to cora"-". alter, improve, demolish,.,
A
W
repair any structure, prior to i,, issuance, also requires the applicant for such
BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to In. Provisions
of ma Contractor's License Law (Chapter 9 Ic.mman<Inp with Section 7000)
�p
AY 1,1.E
of Div hion 3 of the Business and Profession, Coda) or mat he is exempt then'
ASPHALT SHINGLpSI
from and the basis for the .11 ... of exemption. Any violation of Section
7031.5 by any appnc.n[ for a permitubjects the applicant to a civil penalty
I1Y
of not more In., live hundred dollars ($500).):
WOOD SHAKES OF ��
❑ I, as owner of the property, or my employees with wages as mail.01.
Compensation, ill do the work, and the f1,u"[ufo if not intended o1 Offered
for sale (Sec. 7044, Business and Profeasio,n Code: The Contncl.r's License
WOOD SHINGLES
Lew does net apply to en ...or of properly who build, or improve, thereon,
and who dose such work himself or through his own employee., pfovidad that
Such improvement* a not intended or offered for fele. If, however, the
OTHER (SPECIFY)
building or improvement is within one year of owner
�p
of buil .1 p
builder will haw [na fru rdan .1 Droving that M1a did not build or improve for
of
p-rpoesof,..n
.rt S
PROVIDE I.C.B.O. REPORT N0.
mntnni n, with
me progeny, em ec.
❑ 1, a.Contractors
feenaed
70 4.
cod.: Th. C construct the protect (Sec. 7040. Business and Profession,
to co st
t apply toe of property
0.de: The oorbsr[o: License Lawand
PROVIDE MFGR. INSTALLATION SPECS. �
for such proje<tf with e
who ci each p,
wh. bunds) end who
impedvpu
actoracls
sue., t,
contract l licensed pursue., to the ConlractorY license L.W.
PPLICATION DATE
VALUATION PERMIT FEE
❑ I em exempt under Sac. ,Bels P.G. for this
am oder
Ow., Dau
WORKERS'COMPENSATION DECLARATION
F y
�. Building `-t
1 hereby affirm them 1 neva a Certificate of consent to salt inmre, or a ter
tificata of W ,kers CffompenseHon Infura/nfca, or c tilietl copy tbereo`J (Sea
cQ—g,.,
3800. Lela. �05�9L
/
1 S
511141
,
$eI3mIC , t v
P.IicK No, pe y{.90iLCLI1
Certified cony is M1e,abY (wh ish d.
to VTOtel
C.rrin.d CW I ins In ty ifS7 n
Applicant I JE
CERTIFICAT OF EXEMPTION FROM RKERS'N C ❑
—
PERMIT AUTHORIZATION
DATE
COMPENSATION INSURANCE
(This lection need no[ be completed it ins permit is for one hundred dols
Ian 151001 or Iese.).
I certify that m me performance of the work for which this permit
n
issued, I shall not employ anY parson in any manner fo as to to
l�J
m In. Wcleari Comp.naetion Laws of California.
My
Data Appli..n,
NOTICE TO APPLICANT: I. ofbr making this Certificate of Exemption,
you. Should become Subject to the Workers Compensation provisi one of the
Labor Code, you must forthwith Comply with .-ch provision. or this permit
All roofsshall beinspected prior to any roofing material being
shall be deemed revoked.
Installed If a roof Is Installed withOUt first Obtaining an
I certify that 1 have reed this application and state that the ebox. Informs
bon if correct. I agree to comply wish .B city and County crmnanca. and
ins=agreremocall new meterI Isforins action
abs law. relating to building construction. and hereby sumori...p,..n
tamives of this city to enter upon the above-mentioned property for inspection
.
purlpurp..eS.
P...
agree to • indemnify and keep h.fmlesa the City .1 Cupertino
—2
spasm[ liabilities, judgment., costeAnd..Pon.., which may in an- w.y accrue
$I NATU OF APPLICANT DATE
against said City In consequence of the g,enting of his permit. -
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS:
INSP. DATE
INSPP, 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