R-4055OFFICE COPY
PERMIT R_ 4055
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
p
I CIO l� 1�j�
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
d-lelx41or Diems
NAMELI �1�L
FIRE COVERING COVERING
AREA vb CLASS
�-��'
EXISTING ROOF COVERING
ADDRESS -7_+� r 1 L�-�—�-
�
J
S '�
NUMBER OF EXISTING COVERINGS ^:I —
PHONE t_ Imo'
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S
u—'
TYPE OF ROOF COVERING
NAME ' i�
CIT a ZIP IL.4,Yal UI k•
EXISTING
BUILT-UP ROOF
PHONE Cr4L4
ASPHALT SHINGLES
LICENSE I
NUMBER 1
WOOD SHAKES t�
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 em licensed under provisions of Chapter 9 (common
Sectionm
pg with Section 7000) Division 3 of the Business and Professions Code,
WOOD SHINGLES
d my license Is In full �ca and effect. ` d
LicenseClua Lie. Number V
De,. Camrwtur
OTHER (SPECIFY)
OWNER -BUILDER DEC LARATI
I Itereby affirm that I em ...n bpm the Centre or' License Lew for
PROPOSED
the buowing reason. (Sec. 7031.5, Business and Professio Code: Any city
or county which requires a permit to construct, allot, improve, demolish,or
,opal, env structure, prior to its issuance, also requires the applicant for such
BUILT-UP ROOF
permit to Ill. a signed statement that he is licensed pursuant to the provisions
of the Contractors License Law (Chap,., 9 (commencing with Section 7000)
of Division 3 of the Business and Profession Cod.) or that he is exempt there
ASPHALT SHINGLES I
from and the boils for the alleged ...mption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
.f no\ more the, fix. hundred delta,, ($500).):
WOOD SHAKES
0 1, as owner of the property. or my employees with wage, as their sola
compensation, will do the work, and the structure is not intended or offered
for sale (Sec. 7044, Business and Professions Code: The Contractor', Liean.e
WOOD SHINGLES
Law does not apply t0 an owner of property who builds or improve, thereon, ,
and who does such work himself or through his own employees, provided that
such Improvements are not intended or offered for sale. I1, however, the
OTHER (SPECIFY)
building or improvement i sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
purposeof sola.).
PROVIDE I.C.B.O. REPORT NO.
0 I, as owner of the property, a exclusively contracting with licensed
tars to construct the project (Sec. 7044, Business and Professions
contrac
oda: The Contractor'sLicense Law does not apply toanowner ofproperty
PROVIDE MFGR.INSTALLATION SPECS.
who build, or improves thereun, and who contracts for such projects with a
contractor(.) licensed pursuant to the Contractor's License Law.
qq,,
0 1 am exempt under Sac. ,B.&P.C. for this
,..son
LICAT ONlfDATE
VALUATION
PERMIT FEE
Own.. Do,. -
WORKERS' COMPENSATION DECLARATION
VU4) ��
Building fl
I I hereby affirm that I have a certificate of consent to self insure, or a car �/
tificeu of Workers' Compensation In an,., or. certified copy thereof (Sec.
U/. •V�aa
h
Seismic
3800. L.b:
�
L
VN4z' V
Policy No. x-613 ca
Certified copy i. her a ad.
e Car I
/1///�
o
Total
isespy y'inspection division.
Applicant
PERMIT AUTHORIZATION
DATE
CERTIFICA OF EXE TION FROM WORKERS'N C ❑
COM SATION INSURANCE
(This ,ac\ion need not be compl.ted if the permit i, fpr one hundred dol
an; ($100) or Int,.)
1 certify that in the performance of the work for which this permit is
issued, I shell not employ any person in any manner so as to become subject
to [ha Workers'Compass motion Lew, 01 California.
Date Applicant
NOTICE TO APPLICANT: Ii, ef,.r making this Certificate of Exemption.
Volt should become subject to the Workers'Compensation provisions of the
Labor Code, you must forthwith comply with such provisions o, this permit
All roofs shall be inspected prior toany roofing material being
41.11 be daamed revoked.
1 certify that I have read this application and state that the above inform.
installed If a ro S in$tag without first obtaining an
non I. correct. I .gr.a ,. comply with .0 city and county ordin......nd
inspection, I e m all new materials for inspection.
.,ata laws relating to building construction, and hereby authorize rapfesan
,.fives of this city to enter upon the above mentioned property for inspection
pur(We, agree to save, indemnify and keep harmless the City of Cupertino
against liabilities, judgments, costs and expanses which may in any way accrue
awinst said City in consequence of the granting of this permit.
S AT E O APPLICANT ATE
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