R-4109 PERMIT R_ 410 9
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT E KPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S �IJJf�I/f�,y� ROOF
/ yi r G erwtl FIREAR
NAME DOUS COVERING
'� AREA CLASS
ADDRESS (O� L JOyN"N 1� EXISTING ROOF COVERING
PHONE �S3or O NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ,J+ TO BE REMOVED TO BE RETAINED
NAME tG< L49 MWON TYP OF ROOF COVERING
ADD JS. S EXISTING
PHONEBUI - Rii6
LICENSE 2-7- ASPHALTSHINGLES
NUMBER J v WOO A
LICENSED CONTRACTORS DECLARATION
1 It...by affirm,hot I am licensee under provision.of Chapter 9 wpmmen' WOOD SHINGLES
cin, with Section 7000) of Division 3 of the Business and Professions Code,
and my lion.is in full force and effect.
Licari Clm Lic.Number
Dat. Contractor OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractor's License Lew for PROPOSED
the following reason. (Sar. 7031.8, Business and Profeesiom Code: Any city
p1 county which requires a permit t0 construct, alter, Improve, dan ien,pr
repair any structure,prior to its issuance,also requires the applicant for such gUl LT-
permit to file a fined statement that he it licensed pursuant to the provisions
of the Contractor'. License Lew (Chapter 9 (c.mmancing with Section 7000)
of Division 3 of the Business and Professions Code)of that he is exempt there. ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031t by any applicant for a permit ublects the applicant to a civil penalty
of not more that five hundred dollars($900).1: SHAKES
❑ I, as owner of the property,or my employees with wages as their..Is
compensation,will do the work,and the structure is not intended or offered
ror'ole(sec. lose, Business and P.Lfas.iom coda: Tara Com'omor's License WOOD SHINGLES
Law does not apply 10 an owner of property sono build,.1 improves[Hereon,
and sono does such work himself or through his o employees,provided that
such improvement. • no, Intended or offered for tele, If, however, the OTHER (SPECIFY)
building Or improvement is sold within one year plc mplaiion, the owner.
builder will have he burden of proving tarn he did not build orimprove for
cur seofYale.1. PROVIDE I.C.B.O. REPORT NO.
co1, e.
owner
of the property, am exclusively contracting with licensee
mn to
oconstruct ,are project (Sec. 7044, Business and Professions
code: In.Comrec[or•s License Law does not apply to n owner of property PROVIDE MFGR. INSTALLATION SPECS.
who build. or improve.thereun, and who contracts for such projects with a
contractii licensed pursuant to tate Contractor's License Law.
❑ I em exempt under Sec. ,B.&P.C.for this
reason PPLIGATJ0 DATE VALUATION PERMIT F E
Owner Data y 12
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I have a certificate of consent to sell insure,or a car ��� ��
19
[Ifiu'o of WorkeWork.,.'Compenfalion Insurance,or a certified copy thereof(Sac. yae. Seismic
3800,Lab.C.). k9ygyfaYeYe
Policy No. Company
8 Certified copy 1.hereby furnished. n �'�Ur 1 Total
Certified copy is filed with the city inspection dwifio GUrtkI1NO LSCC 'J
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
C ❑ PERMIT AUTHORIZATION DATE
COMPENSATION I NS URANCE
(This($ 0 action need not be completed it the permit is for ossa hundred dots
Ian 15100)or that
i
I cantly tno in the performance person
Ot the work for as ion co permit i.
issued,the I .hall not employ any Lenon in any manner so a.to become tubj.ct
to the Workeri Compen'otion Laws of California,n
Osla Applicant
NOTICEAPPLICANT: Ia
lter making this Certificateof Exemption,
you should become subject to the Workers' Compensation provisions
of the
Labor Cod., rou must forthwith comply with such provisions or this permit All roofsshall be inspected prior to any roofing material being
.null be deemed revoked.
I certify Met I have road this application and state that the above informs ins. d. If a Toof is installed without first obtaining an
tion i, correct. 1 agree to comply with all city and county ordinances and ins a i nr I a remove all new materials for Inspection
nate laws relating to building construction, and hereby autnoriie reprasen'
'olives of this city to anter upon the above mentioned property for inspection a
purpose
(Ill agree to save, indemnify and keep harmless the City o1 Cupertino
s,ain,,
IisbTti.,judgment.,costs and expanses which may in my way accrw
against.aw City in nnseounce of the,noting m In,.permit. SIGNATU F APPLICANT 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