R-3580i
•
OFFICE COPY
PERMIT R- 3580
R-
APPLICATION FOR CITY OF CUPERTINO NUMBER
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 WIPERMIT THIN 11XPIRES OF 80 DAYS OF PERM RK IS T� SUAN COT EED
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS -
- BUILDING USE
—� .
RESIDENTIAL COMMERCIAL OTHER
OWNER'S — -
/
ROOF
NAME ['II CC / T �jl�L
COVVERING
FIRE COVER
AREA CLASS
EXISTING ROOF COVERING ,I
�
46
ADDRESS LL��
y
S-
7
(/
NUMBER OF EXISTING COVERINGS
PHONE .-- !
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME !� G /Vd n'1 V 11 �/ %� J
TYPE OF ROOF COVERING
72
\
ADDRESS
CITY & ZIP 146110
EXISTING
EXISTING
"� °l'— '� p !2 'zl
BUILT-UP ROOF
PHONE
LICENSE i!
ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
affirm that I under provisions arc
1 herewith 9f.. (coon.
of ivisiotl
cing wtrn Section d Proer
3 of m. eL.m... and Prof...mn. cod.,
Tool) of Codm
WOOD SHINGLES
enemy is in lull force mtl alfa<L
ense sand affect.
Class
.at.Cosa Lia Number
.at. contractor
OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Lew for
PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
or county which requires a permit to construct, site, Improve, aemolish,or
repair any structure. prior to its issuance also requires the applicant for Such
BUILT-UP ROOF
permit to fila a signed statement that he is licensed pursuant to the provisions
of the Contractors License Law (Chapter g (commencing with Seciion 7000)
of Division 3 of the Business and Profession, Code) or that he 11 ... mpt tnar.
ASPHALT SHINGLES -
from and the basis for the elluetl exemption. Any violation of Section
)031.5 by any applicant fore permit subjects the applicant to a civil penalty
of not more that five hundred dollars ($5Dm.):
WOOD SHAKES
❑ 1, as owner of me Property, or my employees with wages a$ their sole
<
compee ill ao me work, dna me structure is not or License
1
(Sec. antra t
for dale (sea Two, and Professions coag: The Contractor's herenes
WOOD SHINGLES
Law won not apply to an owner of property builds improves thereon,
o is o
and who does such work himself or through his Own employees, provider that
to
such for sola. 11, the
are not irrTanaae o offeredyear
OTHER (SPECIFY)
ng or iamann
, thew,
building or improvement is sola wi[nin one oxen of completion, the owner
builder Will neva the burden of proving that he did not build or improve for
Purpose of.ele.).
PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the property, em exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Low does norapplytoanowner ofproperty
PROVIDE fill INSTALLATION SPECS.
Who builds or improves thereon, and who contracts for such projects with a
contractor( s) licensed pursuant to the Contractor's License Law.
❑ I am ..amp, unite, Sec. ,B.&P.C. for this
APPLICATION DATE
VALUATION
PERMIT FEE asex
Owner
ow D.re
WORKERS' COMPENSATION DECLARATION
A
Bulldin
I hereby slfirm that I have a certificate of consent to self insure, Or a car.
i / ^
Tificata of Workers Cempen,a,ion Insurance, or a certified copy thereof (Sec.
&J
0
Selsml
3800, Lab. C.).
Policy No. Company
SEP
8 Certified copy Iz hereby furnished,
Certified copy is filed with the city Inspection division.
r b+ T
t . K4A
Total
Applicant
�rL(I
GLiP. RMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'N C El
1ryU
COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dob
1.,. IE 100) o, les..)
1 certify that In ,nit performance of the work for which this permit is
issued, I shall not employ any person in any manner so as to become subject
to Ne Workers compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: 11, after making this Certificate Of Exemption,
You should become subject to the Workers CLm P.oeefi Un provision. of the
Labor Code, you must forthwith comply with such provisions or this permit
,4646 roots shall be Inspected prlorto any roofing material being
shell b. Cesmad ravpked.
1 urfiW thI at have .ear mis application and seta m., m..b... mmrm..
installed If a roof is install Without first Obtaining an
Tien is correct. I agree to comply with all city and county ordinances and
inspection, I agree to rern I new mat Bf a tion.
state laws relating m building construction, and hereby authorize repmem
tatiees of this city to enter upon the above mentioned property for Inspection
purposes.
(We) apru to save, indemnify and keep harmless the City o1 Cupertino
i�
against liabilities, judgments, cons and expanses which may in anV wap accrue
NATURE FAP A T DATE
against said City in consequence of ma granting of this Permit.
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS:
INSP. DATE
INSP. D
INSP. DATE
TEAR OFF INSPECTION:
BATTENS:
FINALINSP.
DATE
INSP. ATE
INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY