R-4003 PERMIT 4003APPLICATION FOR CITY OF CUPERTINO NUMBER R
�
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 1180 DAYS OF PERMIT NOT STARTED
CE
WITHIN
180 DAYS FROM LAST CALLED INSPECTION.
I� BUILDING ADDRESS /� BUILDING USE
8� G �.ir DfL RESIDENTIAL�L COMMERCIAL OTHER
OWNER'S as
HAZARDOUS ^' ROOF
NAME 'h�j 1 I (,/'�f�F`�'CI�-i' �— i0i VFIRE � CLASS COVERING
ADDRESS � `-"' EXISTING ROOF COVERING
PHONE V I NUMBER OF EXISTING COVERINGS
NANTRACT �� /�
N ^VT�Uc I{--`� TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADD
IT 8,RE7�0 .Gli ce
IfXI$TING
PHONE BUILT-UP ROOF
_
LICENSE / /-. ASPHALT SHINGLES
NUMBER C� `Z
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 neraDY affirm that I em licensed unser pmvifiom of Chapter 9(comm as
rasp wkn s«tion]pool of Division 3 of me awinm and Prmeuiom Cad g, WOOD SHINGLE
and my license is In fun force and effect.
Litems Coss Lic.Number
Dav
Contractor OT CIFY)
OWNER-BUILDER DECLARATION
I bat.by affbm that I am exempt from the Contractors License Law for PROPOSED
the following riwi sec. 7031.5. Business and Professions Code' y city
or county which requires a permit to construct, alter, improve emo Or
repair any struatun.prior to its issuance,also re0ulns [nae man+for au BUILT-UP ROOF
permit to fila a signed statement that he b li tensed pun. to he
prow isiont -
01 the Contractors License Lew (Chapter 9 Icommanc with Sam.an]000)
of
Division 3 of the Business he ane..ofe..ran.Cade) e,na is aeamojm0ra_ ASPHALT SHINGLES
from dna the baso for tb allegad a.amp eon. ny v anon a n
]031.6 by any applicant for a parmrt iubja to e00na a civ,lva Ev
of not mora the,five hundred poll...IS50aLl WOOD SHAKES
❑ I.
a of me property, or my pl..... ages asill sol
compensation,wir11 do the work, sod . ructu re i. �, en T�r�tl�or Lice
WOOD SHINGLES �
for axle (Sec. ]004, Business and Profs mm Cotla: n e(f e a Lice
Lew does not apply to.n Owner Of pert who i Or, Ovee Inel
and who 00«WCh work himself ar rOu gas n of r.provided M1at
lith i'"T"nents are not into. ed or off a or . f, howeve the OTHER (SPECIFY)
building a improvement is sold imin one f conM9t.an, Ina
builder will have the burden of or ng that of build or imp. a for
purpose of sale). v w PROVIDE LC.B.O. REPORT NO.
❑ I, as owner of the property, exclusively nV«ting wit licensed
contra tar: to construct fns Train I . 7044, and P ofessions
ode: TheComrmtor'sLicens. Law doeC at apply to PROVIDE MFGR. INSTALLATION SPECS.
wn0 11 or improvat thareun, and who c acts for such or ac Is with a
see pursuant t0 the Can tns
contracted.)licenractor e .Law.
CII am exempt under Sec. P.C.& for this
..aeon PPLICATION DATE VALUATION PERMIT FEE
Ow Dale
her WORKERS'COMPENSATION DECLARATION Building I �"
I hereby affirm that I neve a cari f ice,. i consen, ,a..lr.in.u.e,or a car. ���
tific., of Worker 'Comps./y��,I Inyrr� or a cyy�ie�d c py mar •/] 1r�(t Seismic
3800,Lab.L) �/'I I /p / �'�1 `T7'1•' /� ' I/ , 1Y�vv�7
Policy No. 1�/•CoTn anFy i lt(Jl cam_ MM ^ a�j.
Total
Certified copy is hereby furnished.
8 Certified copy is riled with the city inspection division. C►T�(1 t Ur
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N O O PERMIT AUTHORIZATION DATE
COMPENSATI O N I NSURANCE
(This section need no,be completed H the permit i.for one hundred dol IF
��
bas If1001 o.hat.)
1 certify mat in Me performance of the work for which this permit is
issued, 1 shell not employ any parson in any manner to as to become subject
to the Workers'Compensation Laws of California.
Car. Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you should b«ome subject to ,he Workers' Compensation provisions of he
Labor COs., you must forthwith comply with such provision.or this permit
shell be deemed revoked. All roofs shall be Inspected prior toany roofing material being
I terrify that I have read this application and state that the above Inform.. Installed If a roof is installed without first obtaining an
tion it correct. I agree <e ng cons with all city and county or..races and Inspec ion,I a ree to remove ew materials forinS action.
'ran
lam relating [o building co ply with all city hereby au[nori[a nes and ^ moi
tativas of this city to enter upon the above mentioned property for Insp«tion 3/ /�
purposes. I
IWeI ague s. save,gindemnify costs
and bap es which
may
City of Cupertino
against laid City i wont nue,Leen and expenses which may in any way accrue
awmn.pia ctry in comaapeno of me g.ammg of this permit, SIGNATURE OF-APPLICA 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