R-4012ft
OFFICE COPY
PERMIT Ras 4 012
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSOR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
- BUILDING USE
2 /
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS. ROOF
NAME
F
FIRE N COVERING
AREA CLASS
EXISTING ROOF COVERING
�T!rri-�
ADDRESS
d
_
NUMBER OF EXISTING COVERINGS
PHO "ol 9
CONTRACT
1
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
NAME
ADDRESS 0�� ��
EXISTING
(4082 _,J 6 �y
PHONE 2'22
LE
LICENSE C ��/ ��
NUMBER (o
�/
XLICENSED
CONTRACTORS DECLARATION
1 hereby affirm the, 1 am licensed under provisions o1 Chapter 9 (commm-
Profeuiom
cing with Section 7000) 1 Divia on 3 01 +ea Business and
Code, and my license is Irr.��L}}} Ie antllalnct.LicenseClex �u�1Numbs. �•'�+ G
4AH
Den �(,� c convct
OWNER BUILDER DECLARA ION �}%I hoeby affirm met I em exempt berm tna Contnctoi f License Lew fthe
following reason. (Sec. 7031.6, Business and Profession Coda: AnycityCounty
which requires a permit to construct, altar, improve, demglish,plrepair
structureto its issuance,
rroul... theappliuntforsuchpermit
any prior elm
to file a signed statement that he R licensed pursuant to the provision+of
the Contractors License Law (Chapter 9 (comm...Ing with Section 7000)�`"01 Division 3
Business Professions Coda) he
of the and or that n exempt *here
GLES
from and the basis for the .11...d exemption. Any violation of Section
7031.5 by any applicant for a Permit aubia<ts the applicant m a civil penalty
of not more that Ove hundred dossers (§5001.):
WOOD SHAKES
❑ I, as owner of the property, or my employees with wages as their sola
compensation, will do the work, and the structure it not intended or offered
for see (Sec. 7044, Business and Prolassions tr
Coda', The Conactor'+ Licanta
WOOD SHINGLES
Law tlO rs not apply to an owner of property who builds or improves thereon,
and who does such work himself or through his own employees, provided that
�s ii /'y"
JU
such improvements are not intended o offered for sale. If, however, the
or
S
OTHER (SPECIFY) ��(�a11'A-el/
building or improvement it sold within year of completion, the owner -
r
builder will have the burden of proving that be did not build or improve for
pp.0
q
PROVIDE I.C.B.O. REPORT NO. O� /
❑ 1, e+ owner of ict property, a
as convection with licensed
contractor to construct the project (sec. Joao, Business and Professions
c. 70 4,
Code: The Contractor's License Law does no, apply to an owner of property
PROVIDE MFGR. INSTALLATION SPECS.
wh 0buildsof implilvid; merwn, and who contracts for such projects with a
contractorls) Ii tensed pursuant to the Contractor's License Law.
p em exempt paler sac. ,BSP... for mit
. ..on
APPLICATION DATE
VALUATION
PERMIT FEE
Own., Data
WORKERS' COMPENSATION DECLARATION
I hereby I have 1
Building'.
affirm that rtilicate consent to self -in urs or stet
tilic... of Workeri CPmpani p� Intur.:CZ. or etc. t riled cp bytthereof ISac.
3800. Lab. Galt, _ i R �(� `)l/ C' _ /
/
%
%� 1 .�Seismic�
/
I'�..D
x -r Company lD a'Y�-QE�a'YLLL licr.• [.`�
Policy No F ny 6
1
ar
C tified <Opy t ropy to no
fe
.sniffed C ' d inspayt ioq.
Total
wit city n_dry
lj,:
W"(S.CVYer
Applicant
PERMIT AUTHORIZATION
DATE
CERTIFICIATE OF EXEMPTION FR6M WORKERS' N.C.
COMPENSATION INSURANCE C ❑
(This action need not be completed it the permit is for one hundred dol
ars 1§100) or less.)
Clrtify that In ma performance of the work for which permit it
as
issued, 1 shall not employ any porton in any manner so as to become subject
person co
to tee Workers' Compensation Lam of California.toCalifornia.Appic
Date _
ant
APPLICANT: If.o afro making this
ICEshould
csts of Eons
ation,
you ld become subject to the the
you Workeri ....t provisions
hComp
r Cod c such potion
Labor cpde, most forthwith .amply with m.n provisions or this permit
a
All roofs shall be inspected priorto any roofing material being
mall be deemed revoked.
ld l
I certify that I have read this application and state that the above informa.
Installed. If a roof is installed without first obtaining an
eon is correct. I ages m comply with .0 arty and county ord
rept and
Inspect' I al s t�ew materials for inspection
tau lawn to building aut a
w. construction,and hereby Pr authorize
his city
abov
inspection wives s. this city to anter upon the above mentioned property for inspection
pomp....
(W,)l agree 1.s, u indemnify and keep es the City of Cupertino
r 'f
which
aveinat liabilities, judgments, costs andthe expenses welch may in any way accrue
g
Sr�IGNATU OF APPLICANT ATE
ancon said city in consequence of me granting of mu Permit
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