R 4127 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Ree 4127
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
PERMIT EXPIRES IF WORK IS NOT STARTED
(408) 252-4505 EXT. 228 WITHIN 180 DAYSOF PERMIT ISSUANCE OR
I�
IN DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS / �n r' ' •� IpyE
35 l4AX.� W RESIDENTIAL I�CO�MM�ERCIAL OTHER
OWNER'S
NAME {n ih riiS F- ^ rO' Ua
h HAZARDOUSROOF
FRE COVERING
ADDRESS `W L�� ✓e�"Wr`^'—`�� AREA CLASS
EXISTING ROOF COVERING
PHONEI=2d ^f �l NUMBER OF EXISTING COVERINGS /
CONTRAnCTO�R'S
( r�✓IG. J Com-�>� TO BE REMOVED TO BE RETAINED
NAME
-.� �� TYPE OF ROOF COVERING
ADDRESS
&ZIP 1! 1 I-A • a°b EXISTING
PHONE �� �' 7 BUILT-UP ROOF
LICENSEASPHALT SHINGLES
NUMBER 24� WOOD SHAKESI f tripl UM,
LICENSED CONTRACTORS DECLARATION
1 nether affirm 00 I of Dnns.a unser a Basions of Chapter a(common
Cod., WOOD SHINGLES
clop with Section]000) of Division 3 0l Me Bueinw n Prolesslom Cod.,
end my H..."U i ce and alis'.
Lieen•C Lt..Numbhr
D. con xtor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for
the following anon. (Sec. 7031.8, Business and Professions Coda: Any city PROPOSED W A
or county which requires a permit to construct, alter,Improve, aemollsh,°r
repair any structure, prior to Its Issuance, him requires the applicant for such BUILT-UP ROOF
admit to III.a signed statement that he is licensed pursuant to the provisions � I (]p
of the Contractors License Lew (Chapter B (commencing the, withSanlon the !�A Jpnyl�, 9Lul
of m,and
3 of the Business the and alleged
exemption.
tion. or that he b exempt there ASPHALT SI�I�I,GL•E$
from and the apps for for apeeetl ax•mpts th Any violation o1 Section
of not o that
t fiveapplicant for a permit subjects [M applicant to a civil penalty
of not more twee IW hundred pro dation($500).):em WOOD SHAKES ser OUrtn rel
Ci 1,a owner of the property, or he employees with wend as Meirspa
fom xis(Sic. will do the work, and Ina ens Cods is not intended or Licensee
for lib(Sec. 7044, Business and f Property Ootle: The Contractor's s Lino WOOD SHINGLES
Law sop not apply to an swear of progeny who buildsorimproves thereon,
and who dad such work himself or through nes own emet*. It, provided,that )
such improvements are not intended sold
with Or one
year
for lila. It, however, the OTHER (SPECIFY)
W1 UI� \Ullt/NI/K/1''
building or improvement is Bold wHnin sen• year of of build or the owner
builds,will have the burden Of proving that he ala red build or improv for
°p 31, as own PROVIDE LC.8.0. REPORT NO. �/f—[�L�F(✓'1
1, as owner st the Property, t ( exclusively Businss contractingwith licensed
contractors to construct the atopens (Sec. 7044, Business entl Profauions
Cod.: The Contractor's License Law does no,apply to on owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves Manua end Who Contracts for Such projects with a
contractor(s)licensed pursuant to the Contractor's License Lew.
Om
am exempt sena•. see. ,B.aP.e,for i'
r.. n APPLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION I Building t
I hereby affirm Mat I M1rv•a certificate f consent to self insure,or•car to 4 ^
77 7e-
dficd•oI Workers'Com potion Incur ertifi�copY tnanof(S.C. I/ I/t ' lO��
3800.L.b.l bll'oea t(�� I Q Oc% arsenic
Policy No. gmpany T/ 1
ani sed copy q h eby fur
nisred.
intuied cop 'inn eve ti n Alvis. Total
Applicant
CE RTI TE OF E X1p01vIPjI`ICrN FROM NWKERS' PERMIT AUTHORIZATION DATE
COMPENSA I INSURANCE N.C.
III or
odd not be comp autl i/ Me permit is for one hundred d01
bre(5100)or las.l
I unify that in M. performance of the work for aswhich this permit it
1.In is I shell not employCompensation
any Lenon n any manner so as to become subject
D Me Workers'Compensetlon Laws of California.
Dau Applicant
NOTICE TO APPLICANT: If,o he Workers'making this nsatilceta of Eons pilon,
Lau should become wblest i the mplywih such provisions
nso r this of the
it
Labor Code, you moat forthwith comply Surto such provisions or this admit All roofsshall be Inspected prior roofing materiel bele
Mese be sensed revokes. P P Y g g
I certify Met I have read this application and state that the above Informs installed. If a roof Is Installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinances end Inspection,18 tee t0/em Neall new materialsfor inspection,
able lam relating to building construction, and hereby authorize represem P g
,,fly.of this city to enter upon the ebovsmantionerl Property for insPection 9
purposes'
u L�
(We) agree liabilities, save, en ts,cos s ane keep harmle.whi h thema in a of ay ncfuo
against saidITTi judgments,cease and upends 1 this may In ens'way daue
edinat lila Clty in consequence of the granting of this permit. SILAR OF I DTE
PRE-INSPECTION: PLYWOOD: INNROGR
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