R-4066 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Rox 4066
REROOF PERMIT INSPECTION DIVISION PERMIT E ORKI N
.. PERMIT 180)RES IF WORK I NOT STARTED
(408)252-4505 EXT. 228 WITHIN80 DS F DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZ/ 7�
ROOF
NAME //f/ S ff �YIhS/pN FIRE COVERING COVVERING
AREA CLASS
ADDRESS !/}�)/�l� EXISTING ROOF COVERING
PHONE 7 L/,"—/7b70 NUMBER OF EXISTING COVERINGS Qly-f—
CONTRAC OR'S //J�
.,.4 dres. Po-af,Yyc _ -.47Yc TD BE REMOVETYPE OF ROOF COVERINGED
NAME ta9lvy�
CITY&Zlb Z z (UiyeN 4M. aieio- 6 r. EXISTING
95vo(. BUILT-UP ROOF
PHONE 081 33�-3��9
LICENSE 9 U 6�p _ 7 p ASPHALT SHINGLES
NUMBER ( O d
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I with
affirm 7000 I am❑mead 3 of t provision of dChapterProle s(coons Code. WOOD SHINGLES
cine with S se I.i 70001 of Division 3 01 the Business+ntl Professions Code,
and my Cie. Is in ful�ip/cp-ane a11aC\.
Liunea Clio L S Y Lia Numba� e
Dat. convxmr K,rp�� OTHER (SPECIFY)
OWNER-BUILDER DECLARATIO
I hereby affirm that I am...mpt from tn.Contrwtor. License Law for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Coee: Any city
or county which requires s permit to construct, alter, Improve,eemolish,or
r.pelr any structure.Prior to its issuance,also requires the applicant for such gUl LT-UP R
permit to file a signed statement that he is licensee pursuant to the provisions
of the Convectori License Lew (Chapter % (commencing with Sermon t7000)
here
from
Division 3 of the Business the
and Proalleged
exam tion. or that of a exempt darn ASPHALT H INGLES
from end the anis for the allermi exemption. Any violation of Section
of not o any t five hu fore permit subjects ma applicant t0 0 civil Penalty
of not mar.that rye hundred dollars r my e.❑ WOOD SHA ?7
ES
❑ 1, ti owner of \M Property, or he employees with wends as[noir sola
fompe (Sec. 044will do me work, and the structure is not intended 's offLicense
for ane (Sea ]apply
Bo neo ntl Professions Coda: TheContractor'smracto:s Licante WOOD SH ING S
Lew Woes not apply to an owner of property who builds to ees, oras thereon,
and who don such work not int or ed o rpct his own employees, however,that "� /'
such ng or improv • his old wife or one
year
for cele, u, however,owner OTHER (SPECIFY) /r u
building i improvement t e bur i sola proving
one year of completion, ma
builder will Here me ee.den of proving mat he eitl not build or improvefor
purpO1e Of sea.). PROVIDE I.C.B.O. REPORT NO.
Cl I, a of the property, a exclusively contracting with ncansed
contractors to construct the project (Sec. 7044, Business and Professions
Coda: TnaContractor'sLicense Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who beim. o improve. mereun, dna who convects for such projects with e
contractor(.)li tensed pursuant to the Contractor's License Lew.
❑ 1 em exempt under Sac. ,B.&P.C.for this
reason Data
APPLICATION DATE VALUATION PERMIT FFU
WORKERS'COMPENSATION DECLARATION BuildingkEA r
I Mreby affirm that I have a ertificata of[onset to sell insure,or a car
tifita at Workers Compensation Insurance,or a certified copy thereof(Sec.
P 3800,Lab.C.). f1 p PY B Seismic
Policy No. Company ��
Cartitietl copy is hereby furnished. Total
certifietl COPY is filed with the ci\V in.PacnOn tlivisiOn.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
C AUTHORIZATION
DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit if for one hundred dol CI
I.rs(s1Oo)of I...) �OF CUPtHi1N
I certify ms\ in the performance of the work for which this permit is
issued, I shall not employ any Parsonny manner s9a,to be[o a subject
to ma o keri ompmae\ian Laws of(.ali(pri• �/- _
D s Applicant �GT� �f•"`7r'a"KKR
NOT E TO APPLICANT: If, after m. sun this Certititshe 11Exemption,
you should become subject to the Workers' Compensation provisions of the
Labor Coda. You must forthwith comply with such provision or this permit All roofs shall be inspected prlortoany roofing material being
shell be deam.d revoked.
1 certify that I have read his.ppli[.ron and.eat.the,the above inform._ Installed If a roof is installed without first obtaining an
eon is correct. I agree to comply with all city and county ordinances and Inspection,I agree to emove all new materials for inspection.
.1.1. laws relating to building construction, and hereby outhories represen
tativH Of this city to anter upon the above mentioned property for InspeClion
pea rpos.s.
(We) egrea to save, indemnify and keep harmless the City of Cupertino / N
+g+in.t said
i id liabilities,i consequence
torts and expenses f this
may in nY way accrue
+sin\s+ia City in conegenn of ma granting m suis parmH. SIGNATURE OF APWCAN7 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