R-3961 APPLICATION FOR PERMIT R- 3961 -
CITY OF CUPERTINO NUMBER
R-
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
OTSTARTED
(408) 252-4505 EXT. 228 W THIN 1180 DAYS OF XPIRES IF PERMIT SUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
[._ • RESIDENTIAL X COMMERCIAL OTHER
OWNER'S
/1� a1;2 HAZARDOUS ROOF
NAME /! /� �C FIRE COVERING
AREA CLASS
DR ss .-54th. _ EXISTING ROOF COVERING
7 �5 - NUMBER OF EXISTING COVERINGS I
PHONE
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAMETYPE OF ROOF COVERING
ADDRESS n
CITY&ZIP / �— EXISTING
Sate Jla5e ) / BUILT-UP ROOF
PHONE—
LICENSE
HONE LICENSE / ASPHALT SHINGLES
NUMBER GAJ WOOD SHAKES X
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed..it., ut,w ...of Chapter 9 Icommm
mg with Section 7000) of Division 3 01 he Bu.ines.. a Profe{{Io cede, WOOD SHINGLES p
and my Ci ems b IA fu W ep�r and.sect _� P M I D
License Cfeu Lic.Number
Date Comr«mr OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I baredaffirm that I am exempt from the Contractor'$ License Lew for PROPOSED MAR ].6 1995
the following reason. (Sec. 7031.5, Business and Profession.Code: Any city
or county which requires a permit to construct,altar, improve, d.moli.h,or
repair any structure, prior to its issuance, also rewires the applicant for suchgUl LT-UP R60�r Ut
Permit to file a{tithed statement that he I$licensed pursuant to the provision 6017 I
of the Contractor'. License Law(Chapter 9 (commencing with Section I
of Division 3 of the Business and Profession$Code)or ma[he i$axe mere ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violet of S«ti n
7031.5 by any applicant for a permit subjects the applies o a civil P...I
of not mon that five hundred dollar.(95001.): ODD SHAKES
❑ 1,as owner of the property, or my employees ith wages a 'r I
cz pentatlon, will do me work,and the structure i not intended r tl W OD SHINGLES
for sale(Sac. 7044, Business and Profession.Code' The Contrec tot Ic u
Law dose not apply to an owner of property who udds or imp r t eon,
and who
does such work himself or through his o n e loyee ed met n
such improvement. .•. no[ intended or offers for . THER (SPECIFY) C�m WQQ
building or impr ovemem is sold within one ye of co \i n, the
build., will have the burden of proving that he not r m n
purpose of sals.l. PROVIDE I.C.B.O. REPORT NO. '1312-
0
1, n owner of the property,am..elusively ntr«t nfatl
con❑trectgn to construct the Project ISa<. 7044, B ess nwFir O
ode: The Contractor's License Lew does not apply t now •ofw .ry PROVIDE MFGR. INSTALLATION SPECS. � fdA
who build$ or improves thereon, and who convects for n pr swim a
comrector(s)licensed pursuant to the Contractor'.License Law.
❑ 1 .m exempt antl.• sae. ,B.aP.e.for this
reason APPLICATION DATE VALUATION PERMIT FEE
Owner Oat.
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that 1 have a certificate of consent to self insure,o
bficate of Workers'Compensation Insurance,ora<e[ified copy marsoi(Sac 06 Seismic
3800,Lob.C ��q�c_ �t /�- ^J C Q�
Policy No.(�op,i(Jl.om puny SEAQ/ Q,7s n ` �''��(�� `% /
Certified copy n hereby thrthehed^ —/� �/ J 70181
Certified copy if filed with Ma city inspection division.-
pliunt
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE ///
(Thi{section need he er orm nee it the permit r for dna hundred dols 5
late(S100)or les{.)
1 certify \net in me Performance of The manner
for as which this permit is
toted, I shall not employ any awe o in any man ar so as[o become subject
to the Work Compensation Laws of California.n
Date Applicant
you TCEshould
ld APPLICANT: o afar making this Certificate of Eons of
you .n Cold Deco me subject to the comply
with
Compensation nso r this of the
Labor Cotle, you mon forthwith comply with men provisions or this permit
.hall be tlesmed revoked. All roofsshall be inspected prior to any roofing material being
1 certify that I have read this application and.tate that the above informs Installed If a roof is Installed without first obtaining an
tion b correct. I Agro m comply with all city end comfy ordin«<s aha Inspectlo rBe to remove all new materials for inspection
nate law. relating to building construction, and hereby authorize represem
tett ver of this city to enter upon me above-mentioned property for inspection G
pu'
as
(Wa) ague w sew, indemnify antl keep narml«. me City of Cupartino _ (�
against liabilities,judgments,con{and expenses which may in any way scow
against said City In consequence of the granting of this Permit. GNATURE 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