R-4098 . PERMIT R- 4098
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OIF F PERM T RK IS ISSUA OT CE ORD
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS \1 a - BUILDING USE
a– D, 1 -.1 b V'4�O RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME —1G\ ISG ` ' 0 FIRE CAREA \ CO
ING��, PQc�
ADDRESS ! r' �– (ISTING ROOF COVERING
_
r` `I ? 'la"►SO NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTORnS `�
TO BE REMOVEED
NAME t -�A1 ^C ,/ \ tDn�' 1 C\ A / TYPE OF ROOF COVERING ORESSY&ZI{' Vc0 M��( -1 l ' r'�Cn-
CIIT -,v
EXISTING
o(S(OCD BUILT-UP ROOF
PHONE _
LICENSE ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 nerebr atbn 70001.m N< to ..do,provisions of Chapter
pppggqB Iro1mCmyen WOOD SHINGLES
andwith S_I.i 70001 of D' ilio of tNu Business pntl
end ndY license h i O I�
Do,.+e Cleo ice Number Lo 01
�.J^'
. Pate am contractor OTHER (SPECIFY) !�/ C
OWNER-BUILDER DECLARATION
I nerebr.11 irm that 1 . exempt from the COntr.ctoi s License Law for PROPOSED
the following reason. (sec. 7031.5, Business and Profession.Code: Any city
01 county'which requires • permit to construct, alter, improve, demolish,or
repair any structure.Prior to its issuance,also requires the aoolic.nt for socb BUILT-UP ROOF
Permit IO fila a signed statement that he is licensed pursuant t0 ma provisions
of in Con rector's License Lew (Chapter 9 (commencing wilh Section 7000)
of Division 3 of the Business and Professions Code)Pr that he is exempt mare_ ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation OI Section
7031.5 by any topllunt for. permit subjects the applicant to a civil penalty
of.01 more that five hundred dollars($500).): WOOD SHAKES
❑ 1,as ownar of the ploper[y,or my employees with wage.es,heir sole
compensation, will d0 the work,and the structure is not Intended or offered WOOD SHINGLES
for s 7044, Business and Professionate(Sac. Professions Cods: The Contractor's License
Law do.not apply 10 an owner of property who builds or improves thereon,
and who do.such work himself Or through his own employees.provided that
sucn improvements are not intended or offered 0)r sale. If, however, me OTHER (SPECIFY)
building or improvement is sold within one year of completion, She owner
builder will have the burden of proving that he did not build or improve for
purposePilo
❑ 1, a owner s.). PROVIDE I.C.B.O. REPORT NO.
of the property,am exclusively contracting with licensed
contractors to c nstruct the project (Sec. 7044, Business and Professions
Code: The ContractosLicense Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or mproves thereon, and who contracts for Such projects with a
contractor(s)licensed pursuant to the Contractor's License Lew.
❑ am examot under sap. ,e.aP.c.for this
anon APPLICATION DATE VALUATION PERMIT FEE
owner Date
WORKERS'COMPENSATION DECLARATION C Building
I hereby affirm that I have a certificate OI consent to self insure,or a car �Q�
fificate of Workers'Compensation Insurance.Or a certified copy thereof ISec.
3800Lab.C.). // (�, ` Seismic _!_>OPolic. I�
y No. Com pant Total /�
eCert ilied Copy is hereby furnie cit
Cptired copy a riled with m:city impaction division.
Applicant .'x n g 41
CERTIFICATE OF EXEMPTION FROM WORKERS' N C PERMIT AUTHORIZAYI N DATE
COMPENSATION INSURANCE
(This section hoed not be compl.1. it ape it is for one nundratl dots ^O ,Srgaas�
Par,($100)or Ins.) ��� F%/ IV44V V4
I cotiry mat in the performanc o t wor for which this permit is
Issued, 1 shell of employ any person 'n a an er s0 as to become subject ' e
tom rq.WQ kari�Sympan+elion Laws of i1 ` ,. 'CHI(IVU
Oat Applicant
NO CE TO APPLICANT: If, alter m is Certificate of Exemption,
you should become subject t0,he Work* Omp....lion provision.o1 he
Labor Coda, you must forthwith comply with such provisions or this permit All roofs shall be inspected prlorto any roofing material being
shell be deemre
ed voxad.
I certify sonI hwe reed this application and sena,hal the above inlorma Installed If 8 roof IS Installed without first obtaining an
Don is correct 1 agree to comply with all city and county ordinances and inspection,I agree to remove all new materialsforinspectioR
pate laws relating to building the aboven, and hereby au ty for spmam
turves OI,hi+city t0 ental upon[ate above mentioned property for inspection
Purpose .
(We)l agnea s, sera, indemnify and keep esharmlesswhich a City of ay Cc no
against liabilities, consequence
costs and expanses which they in any war attrue
.winst said City in comaoumce Pt this glinting of this permit SIGNATURE OF APPLICANT
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL
INSP. DATE INSP. DATE INSP. DATE
1 NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY-- _ _ _ _ _