R-4068 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- '4068
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
•(408) 252-4505 EXT. 228 LYITHIN 180 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - BUILDING USE
�ST �1��.QIN�Wo� Kv RESIDENTIAL COMMERCIAL OTHER
OWNER'S /- /
NAME HAZARDOUS ROOF
FIRE COVERING
AREA CLASS
gg j DLitzii l� woeld AV, EXISTING ROOF COVERING
ADDRESS (!
PHONE ZS-7- 9'03 T NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
,,` . TO BE REMOVED `y TO BE RETAINED
NAME V" 1�� 1'S f` /�9 TYPE OF ROOF COVERING
CADDRESS
ITY a ZIP U+/ afion,
EXISTING
PHONE �d66-y��L BUILT-UP ROOF 1s .
LICENSE417�/0�19 ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 herewith S ction 7000) of ivi.i.tl3 .1 provisions of Chapter s(coons Code,
ing wlfn Section 7000) m Dmi.mn 3 of m. ep.moa and Professions Code, WOOD SHINGLES
and mylkanwi+in WI r eand.ffec7. ./ Q/ M
Linme CI Ses Lic.Number T
Dat. Contractor I • OTHER (SPECIFY)
OWNER BUILDEll DECLARAT ON APR.26 1995
I hereby.ffirm that I . mpt from the Contractor'+ License Law for PROPOSED
,he
lollowing r.eson. (Sac. 7031.5, Renin...and Professions Coca: An,oit,
or county which requires a permit to construct,alter, Improve,damolish,or
repair any structure, prior to its issuance, also requires me applicant for such BUILT-UP LT-UP ROOF GI l�Y yr UUrCH I INU
Permit
to fila a signed statement that he is licensed pursuant to the provisions
of the Contractors Ulan" Law (Chapter 9 (commencing with Section 7000) �Q
o+ Division 3 of the Business and Professions Code?or that he is exempt there ASPHALT SHINGLES
from and the bells for the +)Load ...mplion. Any viol.tion of Section
]031.5 by any applicant far a permit subjects the applicant to a civil penalty
of not more mat five hundred dollar.($500).): WOOD SHAKES
❑ I,• of mr a Property,p my employees with wages as their sola
comp.m.tion,will do the work, andthe structure Is not intended or offered
for"Is (Sec. 7044, Business and Prole++ions Code: The Contractors License WOOD SHINGLES
Lew dose not apply to an owner of Property who build+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 i sold within one vsef of Completion, the owner
for
builder will have the burden of proving the,he did not build or improve
purpose.1 Sol..). PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the property, am exclusively contracting with licensed
contractors to construct the Project (Sec. 7044, Business and Professions
Code: TheContracw:a License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
Who builds of improve+ thereon, and who contracts for such projects with a
contractor(*)licensed pursuant to the Contractors License Law.
C3I am exempt under sac.aralln ,e.6P.C.for sola APPLICATION DATE VALUATION PERMIT FEE
oD.7.
Own.,
WORKERS'COMPENSATION DECLARATIONBuilding
dm
1 hereby firthat have•certN
iliceta of cpnaant to seimure,or•taf
tifkel.of Wo.ke.i Compensation Insurance,or a Certified copy Thereof(Sec. Z Seismic
3800'* C.).
Policy No. Company
8 Certified cold,is hereby furnished. Total
Caredse Nro
copy is filed with the city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N C ❑ PERMIT AUTHORIZATION DATE
COMPENSATION N S URANCE
(This section need not be completed if the permit is for one hundred dol
Isla 151001 O.leu.)
I canify that in In. performance of the wo Ior which this permit is
issued, I anal of employ any parson {�}a(+o +7o bacomasubl Btt
to he
1^�a•tion Laws o1�V�-��i \Y.
Det. APPIICant
od
NOTICE O me subject
T: 11,o hear making this Certificate of Exemption,
You *hose d become soble[7 to the Workers
Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
shall be doomed r.vokad. All roofs shallbeinspectedprlortoanyroof(ngmaterialbeing
Ic.Tifv mat I nava reed this application and state that the above informs installed If a roof Is Installed without first obtaining an
non is Corr«t. I agree to comply with .n city and county ordinances and inspec o ee oremove alt new materials for inspection.
nes. laws relating to building construction, and hereby authorize radiation
'Stoves of this city to enter upon the above mentioned property for insp.cnon
purpoeea.
(Vi agrees. uta, indemnify and keep harmless the City of ay accrue
against said City i consequence
cum and granting
f thiwhics mem in any way accrue
against said City In comanoenc.of me g..ntmg of this permit. SIGNATURE 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