R-4420 PERMIT
APPLICATION FOR
CITY OF CUPERTINO INUMBERRas 4420
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /' BUILDING USE
/LSC /� efa 4C/ood RESIDENTIAL COMMERCIAL OTHER
OWNER'S /(� {y
N !/ / ( �L� HAZARDOUS \ ROOF
AME
FIRE �) COVERING
AREA CLASS
ADDRESS 7C� / �/Jfi/ G� EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE W
CONTRACTOR'S
NAME !T//I / TO BE REMOVED TO BE RETAINED
,,, TYPE OF ROOF COVERING
f CIDTOY&ZIP ;2 /� 'J"�l�G�� "� �� EXISTING
PHONE
( ( � BUILT-UP ROOF
LICENSE _ -5
ASPHALT SHINGLE
S
NUMBER / WOOD SHAKES
LICENSED CONTRACTORS DECLARATION /
I hereby affirm that I am licensed under provisions of Chapter g(common
tiny with S«tion ]000) 0+ yi+ion 3 of the Business and Professions cod.. WOOD SHINGLES
and my Ilcanso i�fi B fAl Ind.Nen. _ `�b
Lp.m Ctaa J Lic.Number
D... C.n,r.,., z.Z OTHER (SPECIFY)
O ER UI DER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
,he following reason. (Sec. 7031.6, Business and Professions Code: Any city
.1 County which requires a permit to construct, alter, improve, damOlisho,
reps lr env structure,prior to its issuance also requires the opplican[,or such BUILT-UP ROOF
Pai mi to nIs a signed statement that he is licensed pursuant to the Provisions
of the Contractor's Lic•mo Law (Chapter 8 (commencing with Section 7000)
Of Division 3 of the Business and Professions Code)or that he is exempt there. ASPHALT SHINGLES
from antl tba basis for the ell«etl exemption. Any violation of Section
7031.6 bV any PP an, Ior a permit subjects the applicant 10 a civil penalty
o,not more that Nv.hundred dollen( 600).(: WOOD SHAKES
❑ I,as own.o, he property. or
my employees with wages as their sole
compensation, will do the work, andthe structure is not intended or offered
for ale(S«. 7044, Business and Professions Code: The Contractors License WOOD SHINGLES
Law does not apply 10 an Owner of property who builds or improves thereon,
and who does such work himself or through his own employe.,provided that
such improvements are not intended or Offend for sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
for
builder will have the burden of proving that he did not build or improve
P.,P... Sol
❑ 1, of the property, a exclusively convecting with licensed
con Vectors [o construct ,ate Project(Sac. 7044, Business and Professions
C
Th.Con,,.,pr. LicenaLaw do..no,apply 1....wno,ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves m.eun,and who contracts for such projects with a
contractor(s)licensed pursuant to the Contractor's License Law.
[3I em exempt under yes. ,B.aP.c.for his APPLICATION DATE VALI)!`A PERMIT FEE
Own.,_ Data R) E
WORKERS'COMPENSATION DECLARATIOIf e. BUIIdif�gI I.aby affirm [nam I nva a n Insurete f c , o eell.in.0 re,or acar p/A� �� 11ctificsbofWorkeri Companahon Inwran o cari ed CPPV her f IS ••I/'I el$m3800,Leber ) \�'o }Q Policy No.��S- C Company J I n` •� lY f-
�7 ��7 ' Ur
1 9 C.rvred Copy is filed with the city imp.tI on division. �Uf'tH))(y�Total
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N D ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
This )or
need no, be completed if me permit is for one nuntlred d01 2
fen($I W)or less.l -/
I certify that in Me perlo,menca the wort for which this pa rmiI is
nwad, I shall o,a ploy any pen0, e 9 m Ano so [o became subject
to tee �O eff�a,ion Lows C b / l
Data A/Applicant
NOT( ld APPLIC NT: Of. hear mak' this Certificate of Eons pion,
YOU
should beco
..me su blKt `0
i the mply CPmph provisions
Provisions a tee
Lail be dee edrevos„oanwite comply hat such proviaion+or this permit All roofs shall be inspected prlorto any roofing material being
scall Da seemed evoked.
1 Certify that I have read this application and state that the above informs In fed., If a roof is Installed without first obtaining an
non if con«[. 1 agree ,o comply with all city and county ordinance+and SPBCtI0i1 a e to remove all new materials for inspection
.,ata awe rela,iny ,o building construction. and hereby authorize nproem
ta,ives of his city to enter upon the above mentioned property for inspection (,'
purpofos. 3� /3—/
IWt liabilities.ayr« ave, indemnify end keep harmlesswhich tee City of Cupertino
against syi conserve,costs and expanses which may in any way accrue
against said cdv m<onaquance o,ma granting of this permit, SIGWA34,AE OF APPLICANT 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