R-4216 PERMIT
APPLICATION FOR CITY OF CUPERTINO INUMBERR-a 4 216
REROOF PERMIT 'INSPECTION DIVISION PERMIT EXPIRATION
(408 252-4505 EXT. 228 RK IS NOT STARTED
yITHIN 180 DAYS OMIT EXPIRES IF F PERM T ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - BUILDING USE
DRESIDENTIAL--L— COMMERCIAL OTHER
OWNER'S
" HAZARDOUS ROOF
NAME ., n anA.. aA4_,& i
FREE CLASS ING
ADDRESS 1411 ? ' ,1.12, EXISTING ROOF COVERING
PHO S Z -S I ZS ct- �S NUMBER OF EXISTING COVERINGS
CONTRACTO '
TO BE REMOVED---/-- TO BE RETAINED
NAME G mac. TYPE OF ROOF COVERING
DD
CIITY&iia 90oO �0 hS. `� 0) EXISTING
PHONP��2V6 1 --2 6 7 7 BUILT-UP ROOF
LICENSE / p/ ASPHALT SHINGLES
NUMBER la / WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(comm."
a.9 with section 7090) of Division 3 of the Bti.ine..and Professions Code, WOOD SHINGLES
and my lice.«is M fu111 a end enact �•y O
License CI L J Lim.Numbs I
Lice Contractor OTHER (SPECIFY)
OWNER-BUILD
ER DECLARATION
heteby affirm that I em...mpt from the Contractor's License Law for PROPOSED
the following reason. (Sec. 7031.5, from
and Professions Code: Any City
.1 C.-iffy which I.,uir.a a permit [o c nstruct alter, improve,demoli.h,or
rebel env.tmRun, Prior to in issuance,.11. renuir.,the applicant 101 w<b BUILT-UP ROOF
Permit to it lee signed ssetemem that M1e is lican..d pursumt to the provisions
of ins Contac tory License Lew (Ch spier 9 (Commencing wi to Sac t ion 7ODD)
of Division 3 of the Business and Profession.code)or that he I.exempt Inere ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of S«tion
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more that five hundred dollen($500).): WOOD SHAKES
❑ 1,as owns of he property,ormy employee.with wag..es lheir.ole
com pense[ion, will do the work, and the structure is not Intended or offered
for +ale(Sec. 7004, Business and Professions Code: The Contractor's License WOOD SHINGLES
Lew don not apply to an owner of property who builds or improves thereon,
end who does such work himself or through his own employees,provided that
such improvements are not intended oroffered for sale. 11, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
puipoleof+ale.). PROVIDE I.C.B.O. REPORT NO.
❑ I.
as owner of the property, am exclusively contracting with licensed
contractors to construct the Project (Sec. 7044, Business and Professions
Codi The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who build+ or improves thereon, and who Contracts for such ploie<ts with e
contractors)licensed Pursuant to the Contractor s License Law.
❑ em exempt ender sec. ,asepses for this APPLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION B Building
I hereby affirm that I have ecertificate of consent to self insure.or a car- 1
tificate of Workers Compensation J/�� ofiatl y{py t�e�eo.($ac,F
3800.Lab. // •- a/1 ' . //_ /. SBISff1IC v
Policy No. our Pent�+�/•��6�CC.f/ YJ/Osf.IX IlW o90
�.l Certified Copv i.Here y mrni e0. �' J Total
d'f'Ca.fir.a<op�is - tun �.-in Peclion mvi+i...
Applicant `J
CERTIFICAy OF EXEMPTION FROM WORKERS' PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE N.C. ❑
(This section n«tl not be completed it the Permit is for one hundred tlo)" r
bat($100)or tassel
1 certify that m the performance Person
of the work loo which co permit i.
thd, I shall not employ any person in any manner so as to become subject
to the Workeri Compensation Laws of California.n
Data Applicant
NOTICE TO APPLICANT: If, after melting this Certificate 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 roofsshall be inspected prlortoany roofing materialbeing
.nett be deemed revoked.
I testify that I have read This application and stet.mat the above ini.mri Installed. If a roof Is Installed without first obtaining an
tion is correct. I agree tp comply with all city and county ordinances no Ins action Ia reetorem000 a all new materials for inspee�liioon.
.tan laws rating to building construction. and hereby authorise oepnurry p
.,tires of this City t0 buil upon the raboveuctio .and had byau property for inspection
Purposes.
IWt l abr« s. save, indemnify and expenses
esrmgss the City o1 Cupertino
«sins. IieDiliti«,judgments,costa and sapeme+wM1icM1 they in any way accrue
awimt said City in consequence of the granting of this Permit SIGNATURSAOF APPLICANT 11 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