R-4063 Is e
PERMIT 4063APPLICATION FOR CITY OF CUPERTINO NUMBER R
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS Lt
BUILDING USE
Q�.f4zat • 1NOO� RESIDENTIAL COMMERCIAL OTHER
OWNER'SS�y �J /'
ROOF
NAME 6ftL•a' A-4owAiii .5u4&ERLA^a4 FIRE HAZARDOUS . CLASSCOVERING
ARE �
ADDRESS as Z Q�Z�'f�'JWo�• E{`�X.ISITING .ROOF COVERING
PHONE 252.— 3739' NUMBER OF EXISTING COVERINGS Z
CONTRACTOR'S
1.AI�r��S i7� til TOBEREMOVED� TOBERETAINEO
NAME w 1 /�F���T TYPE OF ROOF COVERING
CITY&ZIP Q10G31 4 Us 011islai S Will Su tI�•�o• EXISTING
PHONE 1944- 9+f f4 — BUILT-UP ROOF
LICENSE471L/Off
/7y ply ASPHALT SHINGLES ZO Y_ !�t��►T�
NUMBER 7 WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I he,",affirm that I am licensed under provisions o1 Chapur 9(common
ino with Section TOM) o1 Division 3 of the Business and PProf , WOOD SHINGLES
and
Lic nu C�anu is II�Y•mme end eifec Llc Number Iar
asslo7
ns Coda
qA
Dere "OWNER
W CDECLAR OTHER (SPECIFY)
Oat I am UILDERexempt
f om the Co ION
nanbn reason.
eam tort . 431.5, trim shed Professions
rofe corn Code; Law for PROPOSED
the following nn req (Sec. permit, o construct,ane Pilar, i pr Codd. Any city
re coo my whlct re, ulna • permit a0 , alsorealter, improve, tlemor suc r
repair any at...go, prior ro its issuance,he i also sed ires,Pur that to
for such BUILT-UP ROOF
P=it the to foe t signed statemLicense
Law mea he is licensed pursuant it the tionprovisions00)
01 Ma Contractor's of the Licemo Lew (Chesser Professions I ode)of that wi aM1 Section)0001 75�cu ELIC
, IC
fr Division 3 of the efor th one gedexmtion, o.snot he is enols[thee.' ASPHALT SHINGLES �eepe. f YL
7031 and the baste lot me alleged exemption, Any violation of section
of of by any ,five hundred
for a permit subjects ma applicant[o a civil penalty
of not more mat five themed property, 15y em WOOD SHAKES P A 1 0
❑ I,n owner OI ma p.o rk, e o he employees with wages es[Hair sola
compenution,will do the work, endthe structure is not intended or ollars0
for gala (Sec. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES pp
Lew does not apply to an owner of property who build%or improves thereon, MIeY 1999
and who does such work himself or through his own employees,provided that
such improvements are not intended o offered for sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within or
year of completion, the owner /�I f1
builder will have he burden o1 proving that he did not build or improve for CI' F �( HTINO
purpose Os sale.). PROVIDE I.C.B.O. POR W&.
❑ I, r of In. property. exclusively contracting with licensed
contractors to c nstruct the project (Sac. 7044, Business and Professions
Code: The Contractor's License Law doe,net apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
wh0 builds or improves thereon, and who contracts for such projects with a
contractorls)licensed pursuant to the Contractor's License Law.
❑ am exempt under sap. ,B.aP.c,for thisnuneon APPLICATION DATE VALUATION PERMIT FEE
Owner Deu
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I have a certificate of cnent to self Insure.or a car
of iceb Leof Work., Compensation Insurance,or acartified copy Itareof(Sea /��/a ► SQISmIC
3800, o.C.I. 'I 7� 31 SOO
Policy No. Company
8 Certified copy is hereby furnished. .
Caroliso Total
copy is filed with the city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
D ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This Certify
section need not er completed o if airkpermitisforone his per OOL a /r
fan($100)Or IesL)
1 certify Inst in me performance o1 the work for which this permit if
issued, I s ell 0a employ +nV Peno� iry� p 4140 of to become subject
to ane motion Lews Qf C� (p/Iln
Den Applicant L(/•^
NOTIC T APPLICANT: 11, eltor making this Certificate of Exemption,
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit All roofs shall be ins acted rlortoan roofing material belt
ah.l1 be deemed .vokad. P P Y g g
I certify that I have read this pplica•ion end luta that the above informs installed If a roof is installed without first obtaining an
Hon is correct. 1 Born to comply with .n City and county ordinances and inspection,I agree to removeall new materialsfor inspection.
nate lewd relating to enter
no the ab above-mentioned
• d hereby wtnod7o nprmn. P rl1 g del�— P
purposes.of anis city to mbr upon the above mentioned property for inspection s
Pur we) ::tolA
we)liabilities.agrn to save, indemnify and keep esharmlesswhich the City of Ch acting �7 7
against id ityi consequence
con one oxPmnf which they in my way actions
against city in connaumpe of the granting of this oermie 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