R-4227Ll
OFFICE COPY
PERMIRox 4227
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 W THIN MIT 180 DAYS OF XPIRES IF R RM T ISSUANCE RK IS NOT TOR
I W DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
-D�2 C"4 P&T
_
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
w`,
W
HAZARDOUS ROOF
NAME n�=ry
FIRE COVERING
AREA CLASS
`
ADDRESS "k --C-1 N
EXISTING ROOF COVERING
s�
7�'
j— Lr�
NUMBER OF EXISTING COVERINGS
PHONE O�
CONTRACT 'S
TO BE REMOVED TO BE RETAINED
NAME
TYPE OF ROOF COVERING
CITY & ZIP
EXISTING
BUILT-UP ROOF
PHONE
LICENSE
ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LIC ENSED CONTRACTORS DECLARATION
1 hereWith S affirm that of licensed 3 of T provisions of d P,.I. s
cog Section 70001 3 of m. Business me vrofafiom code,
Dlnd
WOOD SHINGLES
me my
y I tic aft
is In full force and •heat.
Cie.
License Cie.— ontractor Number
Date Co
Contract.,
OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for
following
PROPOSED
the reason. (Sec. 7031.5, Business and Professions Code: Any city
Or county which requires a permit to Construct, alter, improve, eemolifh,Or
repair any structure, prior to its issuance, also requires the applicant for such
BUILT-UP ROOF
permit to +Ile a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter g (commencing with Section 7000)
of Division 3 of the Business and Professions Code) or that he is exempt there
ASPHALT SH ING
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permitubjects the applicant to a civil penalty
of not more that live hundred dollars ($500).):
WOOD SHAKES
❑ I, as owner of the property, ora my employeas with wages their.01•
compan*aticn, will do the work, andthe structure is not intended or offered
for sea (Sec. 7044, Business and Professions Code: The Contractor's License
WOOD SHINGLES
Law tloa not apply to an own.,of properly who builds Or improves thereon,
and who does such work himself or through his own employees, provided that
such improvements are not intended or offered for sale. 11, however. the
OTHER (SPECIFY)
build ng or improvement is sold within one year of completion, me owner
builds' will neva the burden of proving that he did not build or improve e for
P.rpoaoe sale.)
❑ I, f r of the property, a nclmively contracting with licensed
PROVIDE I.C.B.O. REPORT NO.
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply toanowner ofproperty
pROVIDEMFGR.INSTALLATIONSPECS.
who bis ilas p mproves thereon, ane who convects for such Projects with e
contractor(*) licensed pursuant to the Contractor's License Law.
A
,sukirm❑ 1 .m exempt under s.<. ,axe's... for his
APPLICATION DATE
VALUATION
PERMIT FEE
Owner a
De
WORKERS' COMPENSATION DECLARATION
e
Building
hereby affirm that I nava a cortificata o1 consent to sell insure, or a can
tificata o1 Workers' Compensation Insurance,
��
119
or a certified copy thereof (Sac.
38 00, Lab. C.).
^/
ly
.Seismic
Policy No. Company
e C.rlifiad copy if Hereby ll, men•..
n
cadied copy if filed will, : city inspection division.
v r �urE%fl/ry�
Total
Applicant
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
C ❑
COMPENSATION mplet INSURANCE
(This action need not be completed it the permit if for one hundred dol
Pis 1 or las.l
/I�
..Ili
I certify that in the pada Person of the wort for which tuff permit is
I mall not employ any parson In any manner so a 10 become subject
L
10 the,
to the Workers' Compensation laws of California.
Date AT:
If,
APPLICANT: II, altar making this Certificate of Exemption,
ICEshould
you rhCod b
you ld ma subject til the Workers' provisions me
you such patron
`.bob Code. You mos[ forthwith comply with such Provision or this permit
a
lieu da deemed revoked.
All roofsshall be ins ectad dor to an roofing materialbein
P P Y 9 9
1 certify that I have read this application and state that the above inform.
installed. If a roof is Installed without first obtaining an
Don is correct. I agree to comply with all city and county ordinances and
flan lave relating to building construction, and hereby uthorise represen.
ins ectio I a ree to remove all new materials for inspection.
P g P
Purves of this [ItY to e0nb upon the above mentioned property for inspection
(Ill agree to save, indemnify and keep harmless me City or Cupertino
�/�
7Z
against liabilities, ludgmedn, costa and ..Pa.., which may in any way accrue
IGNATURE OF APPLICANT DATE
against said City in consequence of the granting of 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