R-3980 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Ras 3980
REROOF PERMIT INSPECTION DIVISION PER PERMIT EXPIRATION
(408) 252-4505 EXT. 228WITH(N T EXPIRES IF ED
180 DAYS OF PERMIRK T SUAN COT E
IN DAYS FROM LAST CALLED INSPECTION.
' BUILDING ADDRESS - BUILDING USE
aa�X-�9S7GCif6',L I RESIDENTIAL ✓ COMMERCIAL OTHER
OWNER'S
��h� p 'n HAZARDOUS,,yO ROOF
NAME ��✓1fh FIRE // '' COVERING
G AREA CLASS
AooREss�N,,//� TL�
C � � 4/3+'�__% A EXISTING ROOF COVERING
(PHONE "608) 977_ 1A—; NUMBER OF EXISTING COVERINGS 1
CONTRACTOR'S
�n TO BE REMOVED � TO BE RETAINED
NAME { V Qr� 1''��f`.YL,CI TYPE OF ROOF COVERING
CIDTDV&Zlb 1955 70. / .l 1.Y
EXISTING
PHONE / [
`lyl� Jg q-7)- 7r
-7)— 7r (Q l BUILT-UP ROOF
9
LICENSEO ASPHALT.SHING
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provision.of Chapter B(common.
Cing with section 7000) of Division 3 of me Business and Profession.Code, WOOD SHINGL
and my license 1 12 1 force and efie<t. �/1
Llcmn C sus Con Number l/ o
Data DDECLAr�. OTHER (SPECT Y)
OWNER-BUILDER DECLARATIO U �'
1 hereby affirm that 1 em..amp, from the Contractors 4<ansa Le PROPOSED
the following reason. (Sec. 7031.6, Business and Professions Code: Any city
or County which requires a permit to construct,altar, Improve, demoli.h,or
red.lr...ivuc,ur., prior to in issuance, also requires the applicant for such BUILT-UP ROO
permit to tl Is a signed statement that he is licensed pursuant to the provisions
of the Contractor'. License Law (Chapter g (commencing With Saction7000)
of Division 3 of me Business and alleged
Professions Coda)or that he is exempt there. ASPHALT SHINGLES
bons and the basis for tats alleged exemption. Any the is enem Section
7031.6 by .nV applicant fpr a permit subjects the applicant[o a civil penalty
of not mare mat five hundred dowers( 500).): WOOD SHAKES
❑ I,as owner of ma property,or mV employees with wages n their sole
compensation, will do the work,and the structure is not intended craft...a
for sola(sec 7044, Business and Professions Cod.: Th.Contractors License WOOD SHINGLES
Law don not apply to an owner of Property who builds or improves thereon,
and who don such work himself or through his own employees,provided that
.ucn por
Imrv.ments are Pat intended o offered for a.I., If, however, the OTHER (SPECIFY)
bu ilding or improvement is sold within one year of completion, the owner
builder will have the burden of proving mat he did not build or improve for
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
D I, as owner of the property. am exclusively contracting with licensed
contractor, to construct the project (Sec. 7044, Business and Professions
Cod.: The Contra< w:sLicense Law does not apply toanoW rofproperty PROVIDE MFGR. INSTALLATION SPECS.
who build or improves thereon, and who contracts for such projects with e
Contractorls)licensed pursuant to the Contractor's License Lew.
C:)
I am exempt under sec.son ,B.aP.c.for this APPLICATION DATE VALUATION PERMIT FEE
owner Date
WORKERS'COMPENSATION DECLARATION I D Building
02o-
I hereby affirm that I have a certificate of consent to self.insure,or a car U
'fic.te of Workers'Compensation Insu� certified Cody thereof Ise, 1 I f ysO I
3800,Lae. ` lir �n4 w $eIBmIC
Pali cy No. �-Jlo1npenY J Ir
Partite4p<apy..p.ib,, ,rished APR 1995 Total
Ca:::: Copyispil � In. i in.p..Iion division.
Applicant �l1iyn I I 0E 11 1s
CEFIf1 C E F E%EMPTI N FROM WORKERS' N C ❑ C OF GUFRERM AUTHORIZATION DATE
COMPENSATION SURANCE
(TM1issection need not be completed if the permit is for one hundred Col.
Ian IS100f
1 certify that in tree performance of the work for which this permit is
issued. I she not employ any person in any manner so as to become subject 4�--
to tree Worke%Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: If, after making this Cer[ific.Te of Exemption,
you should become subject to the Workers'Compensation provisions of the
Labor Coda, you must forthwith comply with .ucn provisions or this Dermic
shell be deemed revoked. All roofs shall be inspected prior toany roof Ing material being
I certify that I neve rend this application and stats that the above informs. Installed. If a roof is Installed without first obtaining an
bon is correct. I agree to comply with all city and county ordin.nces aneI e 8B OIe OV a new mgterialsforinspeetion.
IOspe On,
state laws relating to building construction, and hereby authorize lap'".. .jy\'on, Dr1/I
of this city to enter upon the above mentioned property for inspection
purpose omentiproperty
(Wel agru s. uve. indemnify costs
and keep eswhichmless the City of ay accrue .J
against liabilities,judgments,teas end expenses which may in any way accrue
against said City in conswumca of the 9rentinp of his oarmit. SIGNATURE OF APPLICANTV 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