R-4014 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Res 4 014
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYSOF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS'1 BUILDING USE
Yee) res6q Jor RESIDENTIAL COMMERCIAL OTHER
OWNER'S I/� .
NAME Ot- 1 01,ote,n/ n HAZARDOUS COVERING
ADDRESS/ S'►01�1 Wr. EXISTING ROOF COVERING
PHONE 3 //3 NUMBER OF EXISTING COVERINGS
CONTRACTOR'STO BE REMOVED TO BE RETAINED
TTS^ C `_ ' TYPE OF ROOF COVERING
ADDRESS p Vze Ad�,,,.x J or S ..Gsc %J?4i EXISTING
7�8� 7! � u'JSR BUILT-UP ROOF
PHON( - 06 ,
NLICENSEUMBER ����J ASPHALT SHINGLES
WOOD SHAKES n
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9(common
-
cing with Section 70001 of Division of the Business and Plosassions Code, WOOD SHINGLES
and my license Is In full force and affect.
License Class Lic.Number
Data Contractor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor• License Lew for PROPOSED
the following reason. (Sac. 7031.5, Business and Professions Code: Any city
reCounty Which requires a permit to construct, alter, Improve, demolish,or
pany siructuro,Prior to its issuance also requires the applicant for such BUILT-UP ROOF
permit to ills a Signed statement that he is licensed pursuant to the provisions
of the Contractor', License Lew (Chapter 9 (commencing with Saction 7000) '�/
of Division 3 of me Business and Profession,Codel or that he 1,exempt there ASPHALT SHINGLES X -
from and the basis for the alleged exemption. Any violation of Section
7031.6 by any applicant for a Permit subjects the applicant to a civil penalty
of not more that five hundred dollars($500).): WOOD SHAKES
❑ I, as owner.1 the property, or my employees with wages as their sole
compensation,will do the work, and the structure is not intended or offered WOOD SHINGLES - P a
for sass(Sac. 7044, Business and Professions Code; The Contractor's License
Law does not apply to an owner of property who bulla•or improves thereon,
and who does such work himself or through his own employees,provided that
such improvements are not intended o offered for sale. If, r however, the OTHER (SPECIFY) APR 1�1-;39�
building or imm provemaI{ sold Within one veer of completion, the owne
buil Car will have [he burden of proving the, he did not build or improve for
aYrooea of sale.). PROVIDE I.C.B.O.B.O. REO IT NO.
❑ I, es owner of the o.openy, am exclusively<omrecting with beamed 1 1 VUPLr1I IN �
Contra to to construct the project (Sec. 7044, Business and Prof..,...,
Code: Th.Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
.no build, o improves tneroun,and who contracts for such projects with a
ContrN[Orl{)IiConrad pursuant to the Contractor's License Law.
❑ I am exempt under Sac. ,B.&P.C.for his
r....n APPLICATION DATE VALUATION PERMIT FEE
Owner Date ��)
WORKERS'COMPENSATION DECLARATION (�/ Building L
1 hereby affirm that I have a certificate of consent to self insure,or Star / /
ofica,e of Workari Compensation Insurance,or certified copy thereof(Sac. Y / �/� 9�D Seismic V0
3800,Lab.C.I. 1/ I (% C/
Policy No. Company
ecertined cop,b hereby furnished. Total
Ccr toad copy I•filed with In.city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N N.C.
O PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This,action naatl no,be complatatl it he permit/hii
dratl d01
lar•($100)or lees.) 11
I certilY ,hat in the Performance el .M1 work roM1' perm' i{
issued, I shall o,employ any aermn in m men r sme s .c, 1 1.
to the ern oto Dentition Laws 1' rni \V/
Date Applicant
NOT( ICANT: It, a i g thi rii,ice o xemption,
VO u ,h YI become Subject to the Workers Compensan0 provision{OI the
Labor Coda,you must forthwith comply Wirth such P,ovi.ion..1 this Permit
shall be teamed revoked. All roofs shall be inspected prior toany roofing material being
,
I Certify Mot I have .ad this application and ib...he,the above informs Instal ed. If a.roof IS inghal1jed without first obtaining an
tion is correct. I agree to comply with all city and county ordinapce•and j •eC11 I agr to r6 VB II neW eteflalS fOrl SpaCt10R
slab laws relating to building construction. and M1arabv sumo rise .p,..n
,olives of this ci,,to enter upon me above mentioned property for inspection
ourVIO•es.
IWt l agree to bye, indemnify costs
and keep es Which the City of Cupertino
against liabilities, consequence
coal and expenses which may In my way accrue
against said enter inconsequence of the granting of this Permit. PP ANT bAtLe
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