R-4025 APPLICATION FOR PERMIT 4025
CITY OF CUPERTINO NUMBER R�
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 WIPERMIT EXPIRES IF WORK IS NOT STARTED
THIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
46 1 ;JA ' _ - �� �f RESIDENTIAL COMMERCIAL OTHER
OWNER'S
�t/� HAZARDOUS ROOF
NAME , /�' E//in FIRE COVERING
AREA CLASS
ADDRESS Z/� " In C� r.� (� VL (-1r-�(Jr "f' EXISTING ROOF COVERING
PHONE `'l ✓ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
� �� �I q��
NAME f ' \INY ✓Y� U V ♦ `�f�/ �Z' TO BE REMOVE TYPE OF COVERING ED
CITYADD
&ZIP RESS Q ""� 5 �—�- �'� EXISTING
—7—> f
PHONE BUILT-UP ROOF
�'� ✓0
LICENSE ��J / ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I withherebyS+tion that I of ((Genual oder provisions of CM1 apto 9(Common
ting with Section )0001 t Division 1 or me Businan and Proasi n�.t WOOD SHINGLES
and my lice n •h In 11� nal affect. 'J /l•�O'
License C el Lic.Number fes•/
Dat. Cony= OTHER (SPECIFY)
W ER-BUILDER DECLARATI
I hereby affirm that I em exempt from the Contractor's License Law for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
o• county which requires a permit to construct, eller, improve, dem.14hor
repair any structure,prior to its issuance,also requires the applicant for such BUILT-UP ROOF
Permit so file a signed statement that he a licensed pursuant to the provislo ns
of theContractor s License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code)or that he is exempt mere ASPHALT SHINGL FSI D
from and the bells for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty rr�� _
of not more that five hundred dollars($500).1: WOOD SHAKE 19
❑ I,as owner of the property. o•my employees with wages as their sole 'e7
compensation,will do thawork, and the structure is not Intended or offered
for axle (Sac. 7044, Business and Professions Code: The Contractor's License WOOD SH IN9�q!bf,
Lew does not apply to an owner of property who builds or improves thereon, r LUr _
and who eon such work himself or through his own employees,Provided that ��(
uch imp 0).a not intended or offered for sale. I1, however, tela OTHER (SPECIFY)MQVIIZP � ��'�''
building or improvement is sola within one year of completion, the owner
builder will nava the burden of proving that he dial not build or improve for
Purpose of..1..). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sac. 7044, Businan and Professions
Code: The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
vino builds or improves tne•oun, and who contracts for such project.with e
contractors)licensed pursuant to the Contractor's License Lew.
❑ lam exempt under Sec. ,es P.c.m•this APPLICATION DATE VALUATION PERMIT FEE
owner Data
WORKERS'COMPENSATION DECLARATION / BUIId
I hereby affirm mal I M1 ve a certificate of consent to salt insure,or a car ^
oficete of Workers'Com en �t�i 'yInsurance erliti d Py t dol(Sec. 1 C D Sels I L
3800.L01, yy//ths'/ rJ�'pT� / J ///�/
polic er�CorFPadY �-
[ifl.d copy is hereby furnished, Total
cart, iaaypy y f'Iap with I in,, torn d......n/
Applican,_�
CERTIFICATE OF EMPTION FROM WORKERS' N.C.
D ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This action need not be completed it the permit is for one hundred doL 1�
lets($100)or las,)
I certify that in the Performance of the work for which this permit is LI
issued, 1 shall not employ any person in any manner to as to become subject
to ma WorkerWorkers'Compensetion Laws of California,
Date Applicant
NOTICE TO APPLICANT: If, alar making this Certificate of Exemption,
You should become subject to the Workers' Compensation provisions of me
Labor Coale,you must forthwith Comply with such provisions or this p.rmit
shell be deemed revoked. All roofs shall be Inspected prior to any roofing materiel being
I ...Hfv that 1 have read this application and state that the above inform. Installed If a roof is installed without first obtaining an
him is core t. I agree to comply with all city and County ordinances and Inspection,I agree to remove all new materials for inspection.
te laws l.ting to building construction, and hereby authorize repraaem
tatives of this city to enter upon the abovementioned property for inspection
purposes.
(We) agree to ave, indemnity and keep harmless the City of Cupertino /
against liatilitia,judgments,costs and expenses which
against said City in consequence of me starting of this Permit,any way accrue SIGNAT R 05APPLICANT DA
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 _