R-4160 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4160
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
(408) 252-4505 EXT. 228 WITHI N 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESSBUILDING USE
it 'E RESIDENTIAL COMMERCIAL OTHER
OWNER'S 1011Y7 4Y",f�
fJFv tj Ml_ y J HAZARDOUS ROOF
NAME /C u {1 FIRE COVERING
AREA CLASS
ADDRESS 7 tli6pklu TJPOif EXISTING ROOF COVERING
PHONEb NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S / TO BE REMOVED TO BE RETAINED
NAME�Dy / L Ace A"G 60_ TYPE OF ROOF COVERING
CITY&ZIP —/ 705 1_6646,f /-44 sSr Y371.1 EXISTING
PHONE 46.9 2-6.41- 9'9'f_S_ BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER 410 /43 WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I noeby affirm that I am licensed under provisions of Chapter 9 Icommam
ting with Saction 7000) of Divhion 3 of he Business and Profusions Code, WOOD SHINGLES
and my license is in full force and affect.
License Cbn Lic.Number
Data Contractor OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Lew for PROPOSED
the following reason. (Sec. 7031.5, Business and Profession+Code: Any city
Or County which requires a permit t0 construct, alter, improve,demOlifh,or
,.pal any structure,prior to its issuance also requires the ePplic..t for such gUl LT-UP ROOF
Far= to file a signed statement the,he I.licensed Pursuant to the Provisions
of the Contractor's License Law (Chapter 9 (commencing with Section)000)
from
Division 3 0l the Business ane Proalleged
exemption.
xam Cotler or the of is exempt S coonhere. ASPHALT SHINGLES
from and an basis for for alleged eaempts the
Any violation of penalty
of not o any tfive ant re a dollars
subjects LM epplicent to a civil penalty /
01 not more the.five hundred erten(9sy em WOOD SHAKES
❑ I, ti owner o1 the property, or he employees with wends as their sole
compensation will d0 the work,and fns structure ode is n01 intended Or offered
for-ale s no apply
Business and f property Code: The or i Contractor License WOOD SHINGLES
4w woos not s ch to an owner of property who n em or improves thereon.
and who sixes such work M1im+all 01 through his own employees,provided that
Such improvements are not intended or offered for sale. I1, however, the OTHER (SPECIFY)
building Or improvement is sold within one year of Completion, the owner
build., will have the burden of proving that he did not build or improve for
pr.00eeqe.al..). PROVIDE I.C.B.O. REPORT NO.
❑
I.
s owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Law do..no,apply toanowner ofProperty PROVIDEMFGR. INSTALLATIONSPECS.
who builds p improves thereon, and who contracts for such projects with e
Contrmtorls)licensed pursuant to the Contractor s License Law.
❑ under sec. ,B.aP.c. r ten'
I.. n am axemoL for APPLICATION DATE VALUATION PERMIT EE
own., Date , pp
WORKERS'COMPENSATION DECLARATION —•a ® Building
1 I have a Certificate of consent to sell insureor a car
hereby affirm that ,
tificera of Worker.-Compensation Insurance,or a certified copy thereof(Sac. U�yOs Seismic
D
3800 Lab.C.I. / VVV
PoI' V No. -in n
Certified copy areby used. r(/�-` 7ggs /y� Toiler
8 Certified cop s rile mpaction d' +ion. W
Z,51
VA
Rr ATE x M ROM WORKERS' N CRp,.RM1T AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be compinad it the permit is for ora hu rad doh
Ian This s Of I"..)
n)
I certify that in the performance of the work for which this permit is
ifWad, I shell not employ any person in any manner so as to become Subject
to the Workers'Compensation Laws of California.
MApplicant
ICE TO APPLICANT: 11, after making this Ceniflc.te of Exemption,
You should become subject to the Workers' Compensation pro vi.ion.of the
Labor Code, you mutt forthwith comply with Such provisions or this permit All rootsshall be ectad rlortoan roofing material lain
shell be deemed revoked. P D Y 9 g
ICertify ,hat I have read this application and state that the above informs installed It a roof is installed without first obtaining an
`ion is Correct. I agree to comply with at city and county ordinance,and ec
ins tion,1 reeo remove anew ma
to terialsfor inspection.
sate laws elating to building construction, d hereby authorize repra+en. P D
trim of this city to anter upon the above mentioned property for inspection
purposes,
we) agree to save, indemnify and keep harmless the City of Cupertino _ ej
against liabilities,judgments.Costs and expenses which may In env way..Iue
against said City in consequence of the granting of this permit. A E CEEVPPLICANY 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