R-3860 PERMIT R_ 3860
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERMIT NSPECT ON DIVISION PERMIT PERMIT IFWORK
EXPIRATION
ORKIS NOT STARTED
(408) 252-4505 EXT. 228 WITHIN 190 DAYS OF PERM T ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS /', ") p /� - BUILDING USE
Ili,4F �V•( f� "'T'^-'�� /�'-[/L� RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
(> FIRE COVERING
NAME AREA CLASS
ADDRESS
S)i �� EXISTING ROOF COVERING
/
2 �3 40 3 B NUMBER OF EXISTING COVERINGS
PHONE O
CONTRACTOR'S
� 1 ��y'� TO BE REMOVED TO BE RETAINED
NAME /i A QQ ROO F'ir4 n TYPE OF ROOF COVERING
ADDRESS ITY0 '� o 1600 I' 1..�•F-(I`" 9.$� 9 EXISTING
PHONE 'Z(pS-SI �7 BUILT-UP ROOF
ASPHALT SHINGLES
LICENSE ^ 11/
NUMBER Ol /�O WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm mat 1 am licensed neer provision.of Chapter 9(common. WOOD SHINGLES
cin. with Section 700r0y)off a Division 3 of the Business d Profes'I s Code,
and my ncanw^Ia Ie'r6 ct. 'l
aLicensendmyClan -�10 LI`'Numbe' Or OTHER (SPECIFY)
Data :7 Convector
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for PROPOSED
the following reason. (Sac. 7031.5, Business and Professions Code: Any city
or county whlch requires a permit to construct, alter, improve, demolisn,or
repair any structure,prior to its issuance,also requires the applicant for such BUILT-UP ROOF
Permit to fila a signed sOtement that he is licensed pursuant to the provis ons
Of
the Contractors License Law (Chapter 9 (commencing with Section 7000) _
' of Division 3 of the Business and Professions Code?or that he is exempt mare ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more mat five hundred dollars($500).1: WOOD SHAKES
❑ I,as owner of the prop.,,,,or my employees with wage.as their sol.
com penution,will do the work,and the structure is not intended or offered WOOD SHINGLES
for sale(Sec. 7044. Business and Profession,Code: Tn.Contractor's License
Law does not apply to an owner of property sono build..1 improve,In.,.... -Ire
ere.., T /�
and wno does such work himself or through his own employs.'.provided mat -/{ 1bt:y•� L 7ne
H
such improvements are not intended or offered for sale. , however, me OTHER (SPECIFY) f lY� -
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 of.ale.?. PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am exclusively contracting with lic....d
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractors License Lew does not apply to an owner of Property PROVIDE MFGR. INSTALLATION SPECS.
who builds or mproves thereon, and who Contracts for such projects with a
contractor(N licensed pursuant to the Contractor's License Law.
reason I m exempt under Sec. ,S.6P.C,for this ppLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION 11 1 Buildin
I hereby affirm that I have a certificate of consent to self insure,of a Car aY
tificate.1 Workers' Compensation Insurance,or
a Certified copy then of(Sac. Seismic 1,90
3900.Lab-f.A�.✓t �•�-.TC —(J/l[ III: % �y /
Policy NLb La/ Company r k( 1995 Total
&Canflfhed copy hereby furni.M1atl /� }'�'
certified c _.filen Wile he Im6 erao NviWn. .. � Il/ (1G
Appl¢ent AAY' '`L�•CJ LAX
CER IFICATE OF EXEMPTION FROM WORKERS' N D 0 r� IT AUTHORIZATION / DATE
COMPENS INSURANCE
(This section need not be completed i1 the permit is for one hundred Ool
on;($100). Ins.)
1 certify that in the performance of the work for which this permit i '
issued, I shall not employ any person in any manner so as t0 b...m.sublet(
to the Workers'Compensation Law.of California.
DataApplicant
NOTICE TO APPLICANT: If, after making this Ce lifiute of Exemption,
you should become subject to the Work.,% Compensation provision'of the
Labor Code.you must forthwith comply with such provisions.or this permit All roofs shall be inspected prior to any roofing material being
Mall be Beamed rw0ked.
I certlf,that I have read this application and State that Ina above informa installed if a roof is installed without first obtaining an
tion is correct. I agree to comply with .0 city and county ordinances and inspection,I agree to remQye all new materials for inspection.
at.'. laws relating to building construction, and hereby authorize represent (((��1 •.
purpoof this city to enter upon the abovemanboned property for inspection �`vt/v•r's l
pprposaa. ( �Q�-(.. -(�-9.f-
IWeI eprea to awe, indemnity and keep barmiest ma City of Cupertino
against liabilities,judgment$,costs and expanses which may in any war ecvue SIGNATURE OF APPLICANT DATE
against said City in consequence of the granting of this 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 _ _