R-4115 PERMIT
R. 4115
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN IN DAYS OF ERMT�SUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNEHAZ'
C) FIRE
.1 0 COVERING
ROOF
NAME l�-�J
�" f AREA CLASS
AooRE w /¢ EXISTING ROOF COVERING
PHONE S C(y NUMBER OF EXISTING COVERINGS
CONTRACTOR'S TO BE REMOVED TO BE RETAINED
_ NAME- CS:z pco ii Sri . TYPE OF ROOF COVERING
ADDRESS a Z10 EXISTING
PHONE—� 7 - BUILT-UP ROOF
LICENSEA SHINGLES
NUMBER 70 WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapnr 9(common
Ging with Section 7000) of Division 3 of the Business and Professions Coda,
and my license is in full force and affect.
License Clan Lic.Number
Date Contractor OTHER RECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Lew for PROPOSED
the following reason. (Sec. 7031.5. Sutiness and Professions Code: Any city
or county which requires a permit to construct, alter, improve, d•moli0i
rape lr any structure,prior to in issuance.also requires the applicant lot such =ASPHALTSHINGLES permitt0 11le a Signed statement that he i.licensed pursuant t0 the provisions
of meContractor'. License Lew (Chapter 9 (commencing with SecHon 7000)
of Division 3 of the Business and Profe.siom Code)or mat he is exempt tharafrom and the basisfor the alleged exemPHon. Any viol.ti.no1 Section7031.5by any applicant for a permit ubjects the applicant to a civil penalty
of notmora met five hundred dollars(5500).1:
❑ I,as owner of the property, or my employees with wages as their sole
compensation,sawill do the work, and the structure is not intended or offered WOOD SHINGLES
for le(Sac. 7040, Business and Professions Code: The Connector's License
Law do"not apply to an owner Of property who builds Or improves thereon.
and who do"Rich work himself or through his own employees,provided met
bu.h improements are not intended or offered for sale. If, however, the R (SPECIFY)
bv
uilding or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
purpo'..faal..). PROVIDE I.C.B.O. REPORT NO.
EI 1,
es owner of the property. am exclusively contracting with licensed
contractors to construct the project (Sac. 7044, Business and Professions
Cod.: The Contractor's License Law does not apply to an ow of property PROVIDE fill INSTALLATION SPECS.
who bu lids or improves thereon, and who contracts for such projects with a
contractor(s)licensed pursuant to the Contractor's License Law.
❑ 1 em exempt under Sec. ,B.&P.C.for this
r...on PP ICATIO,1'DATE VALUATION PERM( EE
Own.r Data IWI
WORKERS'COMPENSATION DECLARATION ! O Building
I hereby affirm that I have a certificate of consent to self insure,or a carr C. p
tifiub of Workers Compensation Insurance,or a Certified Copy thereof ISea /� Seismic
3800, Lab.C.). U,c
Policy No. Company c 11995Me
Certified 9 Certified copy is hereby furnished. G�< Tote
Certified ropy is filed with me citwicity mspatnOn division.
' ADp11Qol
CERTIFICATE OF EXEMPTION FROM WORKERS' N D ❑ PE I IT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This need atl not be completed if the permit is for one hundred dol.
tan(5100) ti In n
I Cattily that in the performance Of the work for which this permit is
issu
I shell not employ any person in any manner so as to become subject
10 the Workeri Compensation Lew.of California.
Den Applicant
NOTICE TO APPLICANT: 11, alr making this Certificate of Eaamption
you
.h Ould bNOmasa .Object 10 the Worker.' COmp.ns.ti.n provi.iOM th
01 e,
Labor Coda, you must forthwith comply with such provisions or his permit All roofs shall be inspected prior to any roofing materiel being
th.11 be deemed revoked.
I certify that I have read this application and nate that the above inform.. Installed. If a roof is installed without first o tai g an
.lat is laws r•la. I .or.. tp ng wits,construction, .icy am.peaty ormn..s and Inspection,I agree to remove all new m aria sp y
rata . Co recta I to buil. coplwithall and hereby dco nutnonxe phren. f`x7
tat
ivn of this city to anter upon the above mentioned property lar inspection
purpose..
(Wel ages to save, indemnify and keep harmless the City o1 Cupertino
against liabilities,judgment.,cons and expenses which may in any way accrue
against Said City in cans•quance of the granting of this permit. IGNATURE OF APP NT 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 .._