R-4410 PERMIT R- 4 410
APPLICATION FOR CITY OF CUPERTINO NUMBER
Ree
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS MI - BUILDING USE
2141 COU.In'1C31/1S AC5 • - RESIDENTIAL COMMERCIAL OTHER
OWNER'S-7111KA ?, L4NDP\ ` x�' _
vS HAZARDOUS ROOF
NAME FIRECOVE
R
ING
AREA CLASS
ADDRESS LrrFJQ1CCUVfIj $ EXISTING ROOF COVER
ING
G� (/� /v��
r PHONE �—/-7�`�10 NUMBER OF EXISTING COVERINGS
E CONTRACR'F
5ZOC)F 'ti
TO BE REMOVED TOJBERETAINEO
NAME
TYPE OF R• F OVERING
CDYaZIP ^AI EXISTING ?
PHONE
✓2� T✓y� +TV�� 1 c D BUILT-UP ROOF v �u
LICENSE ASPHALTSHINGIF
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 Nearby affirm that I of licensed 3 of provisions of d Profession.
9 on.Code
and worn Section 70001 0+ oinhfon 3 or m•amiss«{and Prof/-9Q19 coos, WOOD SHINGLES
and my license a INulUa�a and aHact. 7,O7J 9 p
Lice CI CCL ^^JJ clic.Number Y 1+ h
Date _moi— Contractor o OTHER (SPECIFY) L/
OWNER-BUILDER DECLARATION Ae
I nearby affirm that 1 am exempt from the Contractor's License Law for PROPOSED �rt 1 Q
the following noon. (S«. 7031.5, Business and Professions Code: Any city Rfr1
or county which requires a permit to construct, alter, Improve,demolish,or
repair any structure, prior to its issuance, also requires the applicant for such BUILT-UP ROOF��Y
permit to fila a signed statement that he a licensed pursuant to Me provisions
of the Contractor's oft License Law Koesterhapter s (commencing e)ortat with Section 70001
from
Division 3 0+the Business and Proalleged
exemption.
tion. o. y v he is exempt S tater. ASPHALT SHINGLES
from and the applicant
for the alleptl exemption. Any violation of S«tion
70]1.5 by any r fix.hu re a permit ubja<n ma applicant[o a civil penalty
o+not moan twat rof the pro dollars($500).):
my em WOOD SHAKES
❑eI,as owner o1 the property, or he employees with wanes as r off avid
compensation,will do me work,and ma structure Cure if not intendedntrto 's License WOOD SHINGLES
for sale no apply
to an
and f p+nfbm Code: The Contractor's is License
Lew who
not apply o l owner o+property who bu iltlt or improves thereon,
and who sow such work nim tell or through roffered woe own emplo Yees, howevetl that
wcn improvements ere not i ld with o neyea for {ale. It, however, me OTHER (SPECIFY)
bun eine or improvement if Iola of ing or
year o1 of builcompletion, save owner
bdilae.will have m.burden of proving that ata em not bdua or improve mr �t
prr0 sI o+$own. PROVIDE I.C.B.O. REPORT NO.
I.
ae ownsr st the he project
a exclusively Business a with lesions
code: Te to t construct ins project Les 70a4.p Business Professions
Code: Tare Contractor's Licaoe Lawand who
co tracts tos such pr of acts with PROVIDE MFGR. INSTALLATION SPECS.
who bmlae o eased p scant t, and who actor s i far eaLa projects with e
Bonbect am l.mot pursuant[o the Conbectorl License Lew.
p 1 am exempt dares. S.C. ,Bl for this APPLICATION DATE VALUATION PERMIT FEE
owns Date y
WORKERS'COMPENSATION DECLARATION Building I�
1 hereby affirm that I have a certificate o1 consent to self insure
ti}i ata Of Workers' Compensation Insurance Ore certified OpytM1ereOf l$ac, 0—IoAn ( )Iter/ (0—
36oQ Lae.c r �4 ` �.l 1 r�7r�i1�7/1r/VJ Seismic
Policy No Co peny_'076TH it
9 Certified copy h hereby mrnienae. Total
Certified Copy is filed with the city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
C O PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit if for one hundred doh
tan($,00)or Ins.)
I certify that in the performance of the work for which this permit is
issued. I snarl not employ any parson in any manner so n to become wbject
To the W.,it..Compensation Laws of California.
It
Data Applicant
NOTICE TO APPLICANT: If, after making this Cenificate of Exemption,
,off should become subject 10 the Workers Compensation provisions o1 the
Labor Code, you must forthwith comply with such provisions or this permit All roofsshall be inspected prlortoany roofing material being
"it be tlaamea rwaked.
1 certify that I have arae this application and tut.Char Ina above informsInstalled If a roof is installed without first obtaining an
hon if card«t. I ant— 1
0 comply with an city end county ordinances and in I e r mor 1 new materials for Inspection.
state laws febtinp to building construction, and hereby autno riza repreri
,.hy�o1 this city to anter upon the abov.-mantionetl property for inspection
purposes.
/6� q
(We)liabilities,apraa 1. saw, Int$,cos s antl keep harmlesswhich Ma City of Cupertino /
apinst sidtyi ludn s encs,costs dna expanses which may in any way eccrva
apaimt feta Bey m consequence of the nrenting of this Dermic SIGNATURE 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