R 4407 APPLICATION FOR CITY OF CUPERTINO PERMIT NUMBEMBERR_ 4407
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 'r BUILDING USE
8 �/ 6 QST STg7 G �� RESIDENTIAL COMMERCIAL OTHER _
OWNER'S
.e�
NAME — S ��=1L I DIS FIRE COVERING
HAZARDOUS ROOF
AREA CLASS
ADDRESS I `a 014 LF�Pr V•�.,F►�a,`la„ tD� � EXISTING ROOF COVERING
PHONE 7 1 9 0 0 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S �I� ^
NAME I���"� �l G V left, V TO BE REMOVED TO BE RETAINED
Tyr OF ROOF COVERING
C°DaZIP lolut —1_JtLf? VkSTfirt
EXISTING
PHONE LOX " Z3*L I�31Z Gvot,t.T�Uo
BUILT-UP ROOF
LICENSE 5 S-2>3 6 ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I o
hhDY tiothat I licensed under Provisions of Ch afters(comment
tinSection
of g with S )000) of Division 3 of e Business and Profiselom cod., WOOD SHINGLES
and my Ilcenu II o and efface t
Llcema CI es Lic.Number O Z_7
33
D.t. q Contractor p� � OTHER (SPECIFY)
ER BUDECLARATION hereby that 1 em exempt
emp, f from m.Contractor's License Law for
the I011owing romn. (S«. 7031.5, Business and Professions Cotle: Any city
hePROPOSED
or county which requires a permit m construct, alar, Improve, demollah,or G
r.palr any structure,prior to It.issuance,also requires the applicant for tush BUILT-UP ROOF Q
pat.it tP file a signed statement the,he b licensed punuen,to the P/oviaions
of the Contractors License Law (Chapter 9 (commencing with Section 7000) 11^
00,
of Division 3 of the Business and Professions Code)or that he Is exempt mem ASPHALT SHINGLES 7�r
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for.Permit subject,the applicant to a civil penalty
of not mora that live hundred dollen($500).): WOOD SHAKES
1,as owner of the property,or mV employees with wage,as their sole
compensation,will do the Work, and the structum is not intended or offered
for Sale (Sac, 7044, Business and ProfessiunsCode: The Contractor's License WOOD SHINGLES
Law does not apply to an ownv of property who builds or improves thereon,
and who does such work himself or through his own employee,,provided that
such Improvomena are not intended or offered for sole. If, however, the OTHER (SPECIFY)
building or Improvement is ..to within ossa year of completion, the owner
Iwill have the burden of proving that he did not build or improvefor
PurPoseo.sale.). PROVIDE I.C.B.O. REPORT NO.
El I, s owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does no,apply toanown.Iofproperty pROVIDEMFGR. INSTALLATIONSPECS.
who build. or improves ther.un, and who contracts Int inch Project.with a
contractor($)licensed Pursuant to the Contractor's License Law. `
rate..n 1 em exempt undo. sec. ,e.sP.D.for this APPLICATION DATE VALUATION PERMIT FEE
Owner Dau
e
WORKERS'COMPENSATION DECLARATION Building
I hereby atk.,.rit inn I neve. certificate of r a cent to eel copy
Ther of(car
3licete of WorkarY Comp tion Insurance,or a certified<oPV thereof(Sea t
3BDD.L.b. ,g% y S _..� �4� Seismic
Policy -L � ompenv 1 ��
ern red copy s hereby furnished, �% Total
Certilbtl copy h filed with the shy inspection division. rX
Applicant \1
CERTIFICATE OFSATION IINSFROMURANGE ORKERS' N C, ElP MIT HORIZATION DATE
COMPE(This section need not be completed it the permit is for one hundred do.
Iva($100)ort) ,hie r
I certify that in the performance of the work for which permit is yv\ V U • t/+///
issu.d, I shell not employ any person n y manner to as to become ll
to IM Workers'Compensation Laws of California.nopersonanya
Data Applicant
NOTICE TO APPLICANT: If, after making this Certificate 01 Exemption,
you should become subject to the Work.,. Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit roofs shall be less
All roo
0911 be deemed ravak.d. petted prior o any roofing material being
certify that 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 a comng cons ructi all city end county ordinancesarepand inspection,Iagra tore oveallpewmaterialsforInspection.
ebb
is
mating to building construction, mal andherebyco authorize n and
ativ.s of this city to enter upon the above mentioned property for Inap«tion
Purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino
against liabilities,judgments,costs and expenses which may in any w.y«true GNATURE OF APPLICA T DATE
.Wn insold City in consequence of the granting o1 this permit.
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 ,—,