R-4412 PERMIT R- '4 412
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 1180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - BUILDING USE
/ /✓ RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZ
NAME ��`�dd /Z1�C/-+.e%/✓C9- FIREARDOUS COVERING
/+ AREA CLASS
ADDRESS EXISTING ROOF COVERING
PHONE .2-5 Z410 ?j NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /
NAME - /I f U ( TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
RESS
CIITOY&Zip AlezLl 7eecno ,l S4,-J2-EXISTING
.__Cr, 95/_ (4 BUILT-UP ROOF
PHONE /y(JSC �S /z7O
LICENSE ASPHALT SHINGLES
NUMBER Z Z WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licenses under provisions o1 Chapter 9(commarr
.Ino with Section 70001 01 Divialon 3 of the Business and Professions Code, WOOD SHINGLES
an,my liana • ff.ct
Lt.."Claes L � i ..lC3 �
Dau C� fra.for OTHER (SPECIFY)
OWNER BUILDER DECLARATION -
1 herby •Nirm that I am exempt from the Contractor's License Law for PROPOSED 7
the followee
ing rson. (Sec. 7031.5, Businessland Professions Code: Any city T
or county which ran,u less • permit to construct,alter. Improve, demolish,or
repair any structure, prior to its issuance, also nouires the applicant lot such BUILT-UP ROOF
o.rmlt to Ill.a.jolted statement that he is licensed pursuant to the provisions 7-C
of the Contractors License Law (Chapter 9 (commencing with Section 7000)
of Division 3 01 the Business and Professions Code)or that he is...mpt there- ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to s civil penalty
01 not more that five hundred dollars( 5001 .): WOOD SHAKES
❑ 1,as owner of the property,Or my employees with wages as mail sola
compensation, will do the work,andthe structure is not intended or offered
for ole (Sac. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
Law does not apply to an owner of property who builds or improves thereon,
and who does such work himself Or through his Own BMpt.ye 1.provided that
such improvements are not intended or
offered for sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year or Completion, Ta owner
bull der will have the burden of proving that he did not build or improve for
purpo..of.a1..). PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the property, am exclusively contracting with licensed
Contesctor. to construct the project (Sec. 7044, Business and Prole..iom
Code. The Contractor's License Low does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereun, and who contracts for such projects with a
contractor(s)Ii censed pursuant to me Contractor's License Law.
C1am exempt under Sep. ,B.aP.D.mr this APPLICATION DATE VALUATION PERMIT FEE
.
..an own., Dat.
WORKERS'COMPENSATION DECLARATION Buildin� �-
I hereby affirm that I have a certificate of consent to self insure,or a car ��y111
tilicess of Workeri Com need 0n Insurance,or a certified copy thereof(Sec. Seismic
3800,Lab. 7 .lyse
Pally No C pony 5. ,c
ti i• copy is hereby furnished. Total
Certified copy N filed with the city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
D ❑ PERMIT AUTHORIZATION DATE
COMPENSATI O NINSURANCE
(This...flan need not be completed if the permit is for one hundred do$
,as(6100)er les..) /
1 certify that in the performance of the work for which this permit is
touetl, I shall not employ ianyon caws o in any manner so n m become subject
t0 the Workers'Compensation Law.01 California.
Oso Applicant
NOTICE should
APPLICANT: if,o afro making this Certificate of Exemption,
phone
you .M1 Cold become subject fes c Workers'Compensation n.ovrsi ons a the
Labor cede, you mast larfnwim.amply with such provision.or his permit All roofs shall be inspected prlortoany roofing material being
shall bs deem.0 r.voketl.
1 certify that 1 hove rad this application and state that the above informs Installed If a roof Is Installed without first obtaining an
ban is correct. 1 agree to amply with all city and county ordinates and inspection,I agree to remove all new materials for inspection.
.I.1. laws relating to building construction, and hereby authorize repessam
utives of this city to enter upon the above mentioned property for inspection
purposes.
(We) agree to • indemnify and keep harmless the City of Cupertino
against liabilities,judgments,Costs and expenses which may in any way accrue
against said City in consequence of the granting 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