R-3981 PERMIT
APPLICATION FOR CITY OF CUPERTINO NIUMBERRaw 3981
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
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
J() J(07 - )02-0-7 FIESIDENTIAL.-)L COMMERCIAL— OTHER
OWNER'S
ROOF
NAME C CV,146 AA 2�NaCa_ FIRE COVERING
HAZARDOUS
AREA N CD CLASS A
ADDRESS- +\�O_ 220 EXISTING ROOF COVERIN
PHONE (14cg�) `� 77- 12-70 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TOBEREMOVED— TOBERETAINED
`RCCE'0�4 TYPE OF ROOF COVERING
NAME '10 C1 —
ADDRESS 3 EXISTING
CITY&Zll� 185— SCL 7
-/C)S `�7 - BUILT-UP ROOF
PHONE 75(D(�)
LICENSE ASPHALT SHINGLES
NUMBER c) WOOD SHAKES
I thereby ffimh the,I am licensed..do,ro.wim.ne.1 Chapter 9(,.Pri
LICENSED CONTRACTORS DECLARATION
Fing with Section 70001 of Division 3 of the Business and Professions Code, WOOD SHINGLE
..it ,license no ff.
m cl�ic.Number fA5.0Q0
License C,
,.Ms Contractor '"llexic i4cn�rk� OTHER (SPECI Y)
OWNER BUILDER DECLARATION
I hereby flirrn that I am ..trip, from the Contractor's License La J
w for
E
Y)
U
In.f Ing rise on. (Sec 7031.5, Business and Professions Code: Any city PROPOSED
.0"ony
1(� �p L
or V hi.h*,.q u I,. . permit to construct,after,improve.d.molish.or
repel tany sur ctur., prior to its issuance, also requires the applicant for uch -UP F
Fermi to file.1 signed statement that he is licensed pursuant to the provisions BUILT ROOF
of the Contractor's License Law (Chapter 9 (commencing with S.cfloh 7000)
of D'vision 3 0 f he B..irnosl and Prof...ion.Code).,the,he I....,or he,.
from and the basis for he alleged exemption. Any violation of Section ASPHALT SHING ES
031.6 by any applicant for a permit subjects the applicant to a civil penalty
.71 not more that five hundred Polls,.ISSOO).): WOOD SHAKES
0 1.as owner of the property,or my employees with wages as th.i,.01.
C.m ponsation.will do the work, and the structure is not intended or offered
,or sale (Sec. 7044, Business and Professions Code: The Contract.,'.License WOOD SHINGLES
Law does not apply to an owner of property who builds or improve$thereon.
and who does such work himself or through his own employees,provided that
uch improvement, .,. ..A intended or Offered for ae. If, however. the OTHER ISPECIFY)
b.idi no or mp,iw.nI is sold within one year of completion, the owner
build.,w ill howis the burden of proving that he did no, build or improve for
Purpose of sea.). PROVIDE I.C.B.O. REPORT NO.
El '. as owner of the property, am exclusively contracting with licensed
contractors to construct In. Project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of Property PROVIDE MFGR. INSTALLATION SPECS.
who builds of improves thereon, and who contracts for such projects with a
contractor(s)licensed pursuant to the Contractor's License Law.
0 1 am exempt under Sec. B.&P.C.to,this
n.aSon ARRLE!%TIf VALUATION PERMIT FEE
Owns, Data_- 4N DATEI
WORKERS'COMPENSATION DECLARATION BUiIding2_qE�-"
l.h.,.b, fli,m he, I have a of consent to self insure,or&car 31995 -5Q wo
tifi -.1 Workers'Comp.n..to. lnsur��ce?a Seismic
38DO!Lab Zw thereof Met. i PR
Policy WCompany
&'Certified copy is hereby turn i.P Total
0 C.1lif4d copy wil-fied wit he GIT( UF UutEHFINU
Applicant
CERTIFICATF OF EXEMPTION FROM WORKERS' N.C.0 PERMIT AUTHORIZATION
COMPENSATION INSURANCE Zq_
IThis section need no, be completed it the permit is for one hundred dol
P'.MI 00)or Isis.)
isausticorl.Hyllh.1 in Me performance of the work for which his permit is
1 he not employ any person in any manner so as to become subject
to:he Workers'Compensation Laws of California.
0. _ Applicant
NOTICE TO APPLICANT: 11, after making this Cortificate of Exemption.
,do should bac.m. subject to the Work.,.'Compensation provisions.1 he
Labor Code, you must forthwith comply with such Pl..W.P.or his permit
081 1 be doemed revoked. All roofsshall beinspected prior to any roofing materialbeing
I Certify he, I have read this application and state that the above nriforma� installed If a roof Is Installed without first obtaining an
ton is correct. I agree to comply with all city and county ordinances and
state I we relating to building construction, and hereby outho inspe ion,I agree to remove all new materials for inspection,
tiltives of his city 1.an,.,up..the above mentioned property for inspection
purposes.. is� L11V-7
(We) ginve to save, indemnity and keep harmless the City of Cupertino
against liabilities,fudgmant%,costs and expenses which may in any v
against said City in consequence of the granting of this permit. SIGNATURE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRES&
INSP. —DATE INSP. — DATE INSR 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