R 4154 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Res A154
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)252-4505 EXT. 228 WITMIN 180 DAYS OFVPERMIT ISSUANCE TED
OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - BUILDING USE
/ifs. RESIDENTIAL COMMERCIAL OTHER
NER S
ROOF
NAME 1 Z� 9 Ii-I FIREARDOU$,� �a COVERING
cC AREA �I CLASS
ADDRI �a2�Q� �iEXISTING ROOF COVERINN
PHONE �J�+ u ®� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S 1
/ 7 Q TO BE REMOVED TO BE RETAINED
NAME /ill TYPE OF ROOF COVERING
s
cITY&ZIP �u • �Q,C EXISTING
PHONE- 312C Ls 3 3 BUILT-UP ROOF
f LICENSE ASPHALT SHINGLES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby•/film that 1 am licensed undo provisions of Chapter B Icnmm.m
cloy with Sectio 7000) of Division 3 of me Busfnos 1 .I .code, WOOD SHINGLES
and my Ilc.h. �e;1n i a end aIfact.
LI< he.Class ` Lic.Number
Dat. conn«tar OTHER (SPECIFYI
OWNER BUILDER DECLARATION
1 hereby affirm that I am a.empt from the Contractors License Law for PROPOSED
the following reason. (Sec. 7031.6, Business and Professions Code: Any city
or countY which requires a permit 10 cons ruc 1, alto, Improve, demolish,.,
r.Pab any afuuctun,prior to its issuance,al require.m.applicant for such BUILT-UP ROOF
permit to file a sgned statement that he Is Ii stud pursuant to the provisions
of the Contractor's License Lew(Chepter�2 commencing with Section 7000) T
of Division 3 of the Business and Pr lesson o )ar that ha is exempt mem ASPHALT SHINGLES
from and the basis for the Wepa 'exe Any violation of Section
7031.6 by any appli...I for.per t• bj a applicant to a civil penalty
of not mora that five hundI.d.d.Im, 1 0 WOOD SHAKES
D1, as owner of the prdpnW, mplOVees With wages as their sole
compenfetion,will do the w rk .lruc tura is not intended or offered
for Sala(sec. 7044, • suano Cod.: The contractor's License WOOD SHINGLES
Lew does not eppI W an w i•property who builds or improves thereon,
and who does such r . r through his own employees,provided that
such impro.0 0 nintended or offered for tele. If, however, the OTHER (SPECIFY)
building or imO1. man Is sole within one year of completion, the owner
builder will h.ve the burt�en of proving that he did not build or improve for
Purpose of ser..)' PROVIDE I.C.B.O. REPORT NO.
1, e9 owner of the property, am exclusively contracting with licensed
contractors to construct the Project (Sec. 7044, Business and Professions J
Code: The Contractor'. License Law does nor apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS. C
who builds or improves thareun, and who contracts for such projects with e
contractor(s)licensed pursuant 1.the Contractors License Law,
Oam exempt cancer Sec- ,B id P.C.for this
r.. n APPLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION .L 1; g
I hereby affirm that I have a certificate of consent to felt insure,or a car. 9
tific.n of Workers Com,.n Ion Insuran e,orgy coruf�ap copy tnaraoi(Sec. ism
3800,Lab 113 9g m �sL/ // r+7:a C/Iy ` '2 n
Poli<]V No. ompeny_. l (� CY 1 I A•,{
I7Certified copy is b...by furnimad. f//• • 9/fix yy Total
Certified copy is filed with the city inspection division. `UF
Applicant
CERTIFICATE OF EXEMPTIONFROM WORKERS' PER MITd[AUTHORIZATION DATE
COMPENSATION INS URANCE N.C.
(This section not be completed it the permit is for one hundred dot
Im This($10s ti ISM.)
n /
I certify that In the performance of the work for which this Pa rmit is
r Issued. I shall not employ any person In any manner..as ip became wblect
to the Workers'Compensation Laws of California,n
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificete of Exemption,
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit All rooisshell be
.hall be claimed revok.d. Inspected prior to any roofing material being
I certify that I have read this application and ante that the above informs. Installed. If a roof IS Installed without first obtaining an
tion i. correct I ague to comply with ell city and county ordinances and Inspection, a to removeall new materials forinapectiorn
ante laws relating to building construction, and hereby authorize repusen p
relives of this city to enter upon the aboya-mentioned Property for inspection -
purpose .
(We) agree to Save, indemnify and keep harmless the City of Cupertino ?_L(S 6
against liabilities,judgments,coats and exoan.es which may in any war'accrue SIGNA RE OF APPLICANT
against said City in consequence of ma
Th.gaming of this permit. 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