R 4224 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER-Roti- 4224
REROOF PERMIT . INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
I (408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
R .180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS ,�C�//J_ BUILDING USE
9-Y7� IO - RESIDENTIAL COMMERCIAL OTHER
OWNER'S "
HAZARDOUS��r6 ROOF
NAME l FIRE {.\ ( ) COVERING
AREA �_ CLASS
S8. ' �` EXISTING ROOF COVERING
' ADDRESS// p c1 � -
PHONE \ � �''-✓S NUMBER OF EXISTING COVERINGS
CONTRACTOR'
TO BE REMOVED TO BE RETAINED L
NAME / � ) EXISTINGTYPE OF ROOF COVERING
ADDRESS
CITY 8l `' ✓`'' �/M lay -
PHONE BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION ,
I m hereby sffirthat I am licensed under provision,of Chapter B(..Mme..
tiny with Section 7000) of Division 3 of the Business and Pral...ion.Code, WOOD SHINGLES
and my licanse 111.4 4M.w find diet t. Y 1" -
License
C Lic.Number U
Da. ContractorOTHER (SPECIFY) P A I D
OWNER"BUILDER OEC LARATION
I hereby affirm that I am exempt from the Contractor PROPOSED
Contractor'. License Lew far p 0 3 1995
the following reason. (Se[.7031.6, Business and Profession,Code: Any city
or county which require, a permit to construct.alter, Improve „��, demolish,or - AUG
Top•ir any structure,prior to In issuance,also requires the applicant for such BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provtslons CITY
r 1� �u
of the Contractor', License Law (Chapter 8 (commencing with Section 7000) V 1 1 V from
Division 3 of the Business the
and ged exem tion. or that of is exempt herSection ASPHALT SHINGLES
from entl the In. for the alleged exemption. Any violation of Section
7031,6 by any applicant for a permit subjects the applicant t°a civil penalty
of not more that five hundred dollen($500),): WOOD SHAKES
[3I,a,owner of the property, or my employees with wage,as their mil
compensation,will do the work, and the structure is not intended or offered
for fele (Sec. 7044, Business and Profession,Code: The Contractor',License WOOD SHINGLES
Law does not apply to an owner of property who builds or improves thereon,
end who does such work himself or through his own employees,provided that
such IThmovemenu are not intended or offered for sale. If, however, he OTHER (SPECIFY)
building or improvement is sold within One year of completion, the owner
builder will hays the burden of proving that he did nm build or improve far
purpose of n own PROVIDE I.C.B.O. REPORT NO.
I, s owner of the property,project ( ee. 70 4, convecting with licensed
contr: Thetors to con tor's the seLw (Sec.notply
BTO an o and Pr property
whons
CodThe Contractor's license and whodoes n°t tract.for..Th
ownergcts Wil Is PROVIDE MFGR. INSTALLATION SPECS.
sun° bullas )l improves Pursuant
t, and who contrera i en such prajacts with a
contrxt am licensed oder Se m the Contractor's License Lew.
To.a.I am exempt °ntleT Sa[. ,B.aP.c.for this APPLICATION DATE ' VALUATION PERMIT F
KA
OW Data
her WORKERS'COMPENSATIONDECLARATION BUIId
I hereby affirm that I have a c ttilicale of consent to self"insure,or a or GO
lilicats of Worker.'Comm, IS
p raylnmr eniliedlietl cop (Se[. / /
3800,Lab. ° /�. O JO Seismic
Pollcyyyyy No. ons an 11
- Corti •d c py she by lurni d. 70181
Certified c with Illy in pyyy���ti on di
Applicant E� y
CE RTIFICE OF EXEMPTION
COMPENSATION INSURANCE O"RAKERS' N C ❑ PERMIT AUTHORIZATION DATE
(This section need not be completed if the permit is for Ona hundred dol (\
Ian(5100)or Ides.)
earth, that in the performance of the work lar which this permit I.
usual, I shell not employ any person in any manner to as to become subject
to the Workeri Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: If, after making this Certificate o1 Exemption,
you should become Subject to the Workers'Compensation prov tel ons of the
Labor Coda, you const forthwith comply with such provisions or this permit All roofs shell be inspected riortoan roofing material being
shall be deemed revoked.eastf _ P P Y g g
unify Mat I bee rod this application and 11.1.the,tn.above inform. Installed It a roof is Installed without first Obtaining an
tion i, correct. I ogre. 1. comply wins .0 city and county ordinances and IOB BCilOn,18 fee l0 fen10Ve eII W malBfial9 tori 8 C1iOR
vete law, Totaling to building construction, end hereby authorize repTHan. P g P
cativo of this city to oto upon the above-mentioned property for inspection
lural agree s. sew, indemnify and keep hsfmln2 which the CityIn
of Cupertino
against nmWn«, consequence
costs and expenses which may In•rev w.V ear,.e
against ofd City inconsequence of the granting of this permit. SIGNATURE OFYIPLICANT - DATE
PRE-INSPECTION: ` PLYWOOD: N-PROGRESS: -
(NSP. 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