R-3507 PERMIT R_ 3507
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4-505 EXT. 228 WPERMIT EXPIRES IF
180 DAYSOF PERMIT ISSUANCE OR
(� 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRES ` BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNERS
�/�
.1/�`�Y 1 F �V \ �.�(_iV I HAZARDOUS ROOF
NAME
FIRE COVERING
'1 AREA CLASS
ADDRESS. -(aZ ,_r')6y11eS, 0V0 Y/1 1 T-) , EXISTING ROOF COVERING
PHONE 01101
1 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ^ n
{n A fl ✓.i,i 1 11" ' I/ �-V'/ ' /1n I /, /J TO BE REMOVED TO BE RETAINED
NAME__ VtII.JN V Y 1 V v I r—l.c� l.(�(/✓`L� TYPE OrROOF,COVERING
conari
a 4',�?QIAMV6>4-L �JL1r,4- QCG f2 \
ry'���� V EXISTING
PHONE 4L4� —0"1 177 BUILT-UP ROOF
LICENSE �Lv� l A ALT SHINGLES
NUMBER v✓ I WOOD SHAK
LICENSED CONTRACTORS DECLARATION
I hs.by ii that I am licensed under provision•of Chep»r 9(comma
mMg will Section 7000) of Division 3 m the Business and Professions Co WOOD S I S
e mr nc.n»1•m f Il .•esti even.
Licema Clan Lic,Number
Data Contractor OTHER (FYI\
OWNER-BUILDER DECLARATION
I heubY •tfirm that I em exempf from the Contractor'. License Le for P OP E
in.following recon. (Sec. 7031.6, Buslneas and Profession Cada: Any ify
Or county which requires a permit m construct,alter, improve, damOliM
repair env structure,prior to its Issuance, also requires the applicant for su r -UP RO F
Permit to rue a signed statement that he is licensed pursuant to the provision .
of the Controctor's License Lew (Chapter 9 (commencing with Section 7000)
of Di.ision 3 of the Business and Professions Code)or that he is exempt there ASP ALT SHINGLE$
from and the basis for the alleged exemption. Any violation of Section
7031.6 by any epPl is ant for a permit subjects the applicant t0 a civil penalty 91 yL 1 D e
of not mora that five hundred dollars 16001.): WOOD SHAKE P W
❑ I,as Owns of the property, o my employees with wages as their sola /
compensation,will do the work, andtheStructure is not intended or oflera0 ODD SHINGLES
for sale(Sec. 7044, Business and Professions Code: The Contractors License FEB 81995
Law dos not apply to an owner Of property who builds or improves thereon,
and who does such work himself or through his own employes,provided that
such improvements are not intended or offered for sale. It, however, the 0TH ECIFY)
building or improvement is sold within one year of completion, 1M owner
bull der will have the burden Of proving that he did not build or improve for C11 Y Ur tlurch 1INU
Purpose Of sale.l. PROVIDE I.C.B.O. REPORT N0.
❑ I, as owner of the property, am exclusively contracting with licensed
Contrac tors to c mvuct the project (Sec. 7044, Business and Professions
ode: The ConVxtorI License Law does not apply to an owner of property PROVIDE Ill INSTALLATION SPECS.
who builds or improves thereun, and who contracts for such projects with a
contractor(•)licensed pursuant m the Contractor's License Law.
❑ Ism exempt undo. Be.. ,B.aP.c.fes.thisreason APPLICATION DATE VALUATION PERMIT FEE
Owner Date z�
WORKERS'COMPENSATION DECLARATION QQ Building I o
ok
1 hereby affirm that 1 have a urtificab of c ant 10..If insure.or a car
titin»Of Workers'Compensation Insurance,or a certified coot',thereof(S.C. �j (J! /�� O Seismic t 7e
3800, Lab.U /'Ln lC (L . ,.. .,V Z ^\/�—Ir J LV•
Policy No. Company •�I GVII r 1�1/V lL9l- Total
o_Ce Titled copy is hereby furnished.
$Certified coPV' ilap the Icy ift•pe{tign CivyNq.
A IiUnt L/r/L�( �//
CERTIFICATE OF E MPTION FROM WORKERS' N.C.
D ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol
I."IS 10111 or hC
1 earfity that
ef iwhichthisn the performance of the work for which is Permit is
issueQ I shell not employ any person in any manner so as to become subject p
to the Workeri Compensation Lew.of California. 0
Date Applicant
NOTICE TO APPLICANT: 11, atter making this Certificate of Exemption,
You should become subject t0 the Workers' Compensation provisions of the
Labor Code, you moat forthwith comply with Such provisions or this permit All roofs shall be inspected prlOrtO any roofing melerialbeing
M•II be deemed revoked.
I certify that I nava read this application and state that the above informs. Installed. If a roof is installed without first obtaining an
hon is corr.pt. I agree tp Comply with .11 cilli and county Ordinances and inspection,I agree to remove all new materials for inspection.
s»te laws r.,.ting to building com ruction, and hereby authorize spresem
Ili Of this city t0 enter upon the abovementioned property for inspection
purposes.
(We) ogres to save, indemnify and keep harmless She City o1 Cupertino
against liabilities,judgments,cons and expenses which may in any way accrue
again t said City in consequence of the granting of this Permit. SIGNATURE OFA P ICANT 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