4402 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Roo 4402
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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 J���p����' BUILDING USE
/D0 - ,4 RESIDENTIALK COMMERCIAL OTHER
OWNER'S p
ROOF
}'J � �/ •�' Ir�/ QOS HAZARDOUS
NAME FRECOVER
ING
AREA CLASS
/ �% \T
ADDRESS IST( G ROOF COVER
NG
� NUMBER OF EXISTING COVERINGS
PHONE
/
CONTRACTOR'S '\
TO BE REMOVED— TO BE RETAINED
.NAME //�, TYPE OF ROOF COVERING
,ADDRESS
a Zile �� fei 44,Le _5 LL ee EXISTING
kPHONE'\ 5 SY al"77 BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER Z& V WOOD SHAKES
LICENSED CONTRACTORS DECLARATION 3/
1 hereby affirm that I am licensed under provisions of Chapter B(commen-
[iny Wim Section 7000) of Division 3 of the Business and Plot...ions Code, WOOD SHINGLES
and my license Is f rce and effect.
License
Clan LI..Number OTHER (SPECIFY) O!/
Det• Ctm for '
OWNER-BUILDER DECLARATIO
I hereby eRirm that 1 am exempt from the Contractor's License Law for PROPOSED
the following anon, (S«. 7031.6, Business and Professions Code: Any city
or county Which requires a permit to construct, alto,Improve, demolish,or
repel any structure,pilot to In issuance, also requires the applicant for such BUILT-UP ROOF .f
perm@ to Rn is all.1.1..ent that he is licensed pursuant to the provisions
of the Contractor's License Lew (Chapter B (commencing with Section 7000)
of Division 3 of the Business and Professions Cod.)or that he is exempt more. ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section is
7031.8 by any applicant for a Permit subjects the applicant to a civil penalty
g`�
os not more that live hundred doper.( 600).): Y WOOD SHAKES 41 1)
❑ 1,a.own«of the property,pr my employe.with wagaa at their..I. �s-�
cons pene.lon,will do the work, and the structure is not intended or offered WOOD SH(NGL {/iA'
for life (Sec. 7044, Business and Professions Code: The Contractor's License
Law do.not apply ro an own.,of property who builds or improve.thereon,
and who does such work himself or through his own employees,Provided that Yr� ��
.uch improvements era not intended or offered for set., If, however, the OTHER (SPECIFY) C) Q fir'
bei Id ng or improvement is .old within one year o1 completion, the owner
builder will have the burden of proving that he did not build or improve for
Purpo..piaele.J' PROVIDE LC.g.O. REPORT NO/NU
❑ 1, . owner of the property, am exclusively contracting with licensed
contractors to construct the Project (Sec. 7044, Business and Profession.
Code: TheContr«sur'sLicenseLawdoesnotapplytoanownerofproperty PROVIDE MFGR. INSTALLATION C
who builds or improves maroon,and who Contrams for Such projects with a
contractorO licensed Pursuant to the Contractor.License Low.
reason I am exempt under Sec. ,B,J P.C.for this
Owner Data APPLICATION DATE VALUATION ERMIT FEE
WORKERS'COMPENSATIONDECLARATION e) Bullding
I p
hereby affirm that 1 have a rtificele of Consent to .If insure,or a car
tificete 01 Work.,.Compensation Inwr�enc�j�y� certl/l'i'd copy thereof Roc. /L/f` / /w�/�//w� SBIBmIC
Policy Lab. r`/Pen V `tee /�li"'a� / / /1C
300 ab CbHf y�
9 Corti fieri Copy i)-hare umi.h• Total
Cartlli•tl cop m• y ininspa[tion division.
Applicant
1 C:
1 CERTIFICAT F EXEMPTION FROM WORKERS' N C El PERMIT AUTHORIZATION DATE
COMPENSATI O N I N S URANCE
(This Section need not be completed If the permit is foe one hundred dal *17
I.e.($100)or Iol
1 Certify Chet in me performance OI the work for which this permit is
issued. I mall not employ any person In any manner to as to become subject
to the Workers'Compensation Laws of California.
Dat• Applicant
NOTICE TO APPLICANT: 11, after making this Certificate of Exemption,
You mould become Subject to the Workers' Compensation provisions of the
Labor Code,you must forthwith comply with such provision.or this permit All roofs shell be Inspected prior IOOfIO material lain
.hall be claimed revoked. Q Q Y g g
Icertify that I have .ad this aPplic.lion and late that the above informs- installed. If a roof Is Installed without first obtaining an
tion is correct. I agree to comply with .11 city and county ordinances and
sbte law. noting to building ino theabovo- and hereby authorise spres.m IDSpeCtiO 89FQ��rem0'/%V2, v 11materials for SPBCt100.
burpo of t,is city[o•nnr upon the ebov m•n[lonod property lot insP«tion {/�/i/[/ ��
purposes. /
(Wa) abr•• s, save, indemnify and keep eharmless which the CityIna of Cupertino accrue _-
e"Irst liabilities. consezue costs and he gXpensgl which may In any wry aecma '
ewinu said City in romeoumu of me granting of this permit SIGNATURE APPLICANT 'DAT �—
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