R-3996 PERMIT R• .3 g 9 6
APPLICATION FOR CITY OF CUPERTINO NUMBER
\ REROOF PERMIT 252-INSPECT4505
N5IVIsiGN PERMIT E ORKI N
PERMIT EXPIRES IF WORK I NOT STARTED
(408) 252-4505 EXT. 228 WITHIN S F DAYS OF PERMIT ISSUANCE OR
IBD DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - BUILDING USE
IVL/ / ,?� 3 RESIDENTIAL COMMERCIAL OTHER
OWNER'S /'� /�
—7jyy_ Y/ 1 1 ) HAZARDOUS ROOF
NAME /BUJ .0/D�.1J0� FIRE COVERING
C' AREA CLASS
ADDRESS c—J�Y)'12— EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACT 'S .
TO BE REMOVED TO BE RETAINED
NAME 2. TYPE OF ROOF COVERING
CIT&ZIP / 470 EXISTING
L � 51246 a l2 L' BUILT-UP ROOF
PHONE 0
LICENSE C / y ASPHALT SHINGLES
NUMBER rc0lo(O(o 11
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I herewith S affirm 00 I of licensed 3o f t provisions of Chapter 9 Icommeo-
inp with Section UL of Division 3 of ma Business and P.orn.i s. Peet WOOD SHINGLES
and my license I fuL iB a and attest. 6
Daante CI Lia Numbs
Data �' Contrsclo OTHER (SPECIFY) pp
OWNER-BUILDER DECLARA ON P A I
I hereby affirm That I e exempt from the Contracts:s License Law for PROPOSED
the following reason. (Sac. 7031.5, Business end Professions Code: Any city
or county which requires a permit to construct, miter, improve, eemolish,or
repair any structure,prior to its issuance, also requires the applicant for such BUILT-UP ROOF MAR 10 1995
permit to fila a signed statement that he if licensed pursuant to the provisions s
of the Contractor'+ License Lew (Chapter 9 (commencing with Section 7000)
or Division 3 of the Business and Professions Code)or that he is exempt there ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
90]1.6 by any applicant for a permit subjects the applicant to a civil penalty
of not more that five hundred dollen( BOO).1: WOOD SHAKES
D I, a owner at the property, or my employees with wages as their Iola
compensation, u1 do the work, dna the structure is no, intended or offeree WOOD SHINGLES
for Sells(Sac. 7044, Business and Professions Code: The Contractor'[License
Law don hat apply m an owner of property Who build.or improve,mason, -
and who does such work himself or through his own employees,provided that
such Improvements are not intended or offered for tale. It, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
Purpose 1 of[die). PROVIDE I.C.B.O. REPORT NO.
I, r. owner st the property, t ( exclu044, contracting with licensed
aon[/actor.The Contractor's[gmtma project (Sec. tap Business and Profes.ions rty
ode: old, orpovsthcen+e Lowand who
contracts
for
such
prr of ojects with
a PROVIDE MFG R. INSTALLATION SPECS.
wM10 Duior( or improves scant t, and who contras ter en inch vrgiects with e
contrac[am licensed under Se to the Contractor's License Law.
O I em exempt antler Sec. ,6.b P.C.far,hie
reason APPLICATION DATE VALUATION PERMIT FEE
Ow Date
Own., WORKERS'COMPENSATION DECLARATION 09 Building raj L1�
I hereby affirm that 1 have a certificate of consent to self-insure,or a car I �1 / p
'800, at WOrkV� DOmpensatien lnf�lOCe� cenili9E Copy meredt B.T. 3/�0 7� /OO pel$ml(i
3600,Lab. n.fes/�C/J I f it / !y
Policy No. Genry' 4 Li
yYCarufiw cops:+haseb, .nee. Total (u,9v
AA Csr,itiaE�p a w' ,m:cit.yp lctigr�pwi.ion.
Applicant 7
CE RTIFIC TE OF EXEMPTIONLFROM WORKERS' N C PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hu rad
tart(5 100)or Ins.) 3-60 Q
I certify Inst in the pemance rforof he work for which is permit is "7
its ad, I m111 nqt employ any pal+gas in any mannel+0 at to COme.ubjeCt T���fff to the Work..'Compemation Lew.of Calitorn is. /l \V
ll
Data Apphcan[ t/-/y`/`
NOTICE TO APPLICANT: If, .1., making his Car C. of pts sin, P'�
you mould become Subject to the Work.,, Comp. atiyn 's f the J
Labor Code,yo must forthwith comply with ere provi,Idn n paintle -1All roofs shall be inspected prior to any roofing material being
.hat be deemed revak.dl.
I cosily that l haee rano mi.eppli fon ad ltd., bov.I to installed If a roof is Installed without first obtaining an
Iion is .dint. I .gr.. I. comply Wi .11 city eine .aninspectI feet move all new materials for inspection.
at... laws relating to building construe on, and err uaujjll�� t ase
.lives of this city to enter upon the abov 'men 'o Opo\{?pr Impart n /J // p
purpoteli J /�{ r
we) agree to save, indemnify and keep Semite t • City of Cu rtino !y/��
.gaunt liabilities,judgments,costs and upama M1ic aY in any w accrue g
.gaimt said City in consequence of the granting o his Permit. SIGNATURE OF APPLICANT DAT
• PRE-INSPECTION: PL 00 . 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