R-3927 PERMIT 3927
APPLICATION FOR CITY OF CUPERTINO NUMBER R-
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 WI
PERMIT EXPIRES IF WORK IS NOT STARTED
THIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS C}y� �yy� BUILDING USE
'som (/1 a `\ wly L 1 � \ - r RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME FIRE COVERING
vvy�' /� V� pJ
AREA CLASS. EXISTING ROOF COVERING
ADDRESS
PHONE
6 Iii- i NUMBER OF EXISTING COVERINGS
CONTRACTOFj'S/1 ! �� / -
NAME L/�I /vl"Al. �A /0 --,) TO BE REMOVETYPEOF ROOF COVERING
ED
CITY&Zia EXISTING
PHONE �l (� BUILT-UP ROOF
LICENSE X ASPHALTSHI GLES
NUMBER U
WOOD SHAK
LICENSED CONTRACTORS DECLARATION
I hereby affirm the'1 em licsnatl nder provisions of Chapter 9(common
[ills with Section i000) of Division 3 of the Bmmess and Professions cod.. WOOD SHIN LES
and my license is in full force and effect.
Ucense class Contra for OTHER (SPE IFY
Leu Contractor
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for PROPOSED
the following reason. (Sac. 7031.6, Business and Professions Code: Any city
Or County Which requires a permit to construct, alb,, improve,demolish,.,
repair any structure.Prior to its issuance,also requires the applicant for such BUILT-UPR OF
Permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
oI Division 3 of me Business and Professions Code)or that he is exempt mare ASPHALT S INGLES
from and in basis for Ne II."tl a emption. Any violation .f Section
7031,6 by any appli am" fore permit ubjects the applicant t0 a civil penalty
oI not m.a that five hundred dollen(9500).1: WOOD SHAK
1,as owner of the property, or my employees with wages a their sola
compensation,will do the work, and the structure is not intended or offered WOOD SHINGLE
for ale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of Property sono builds or improves thereon.
and who does such work himself or through his own employees,providedthe, [J
such improvements are not intended or offered for ala. H, however, the THER (SPECIFY)
bu:ding o improvement is sold within one year of comple,ion, the owner
builder will have the burden.1 proving that he did not build or improve for
Purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
O 1, as owner of the property, am exclusively contracting with licensed
controc ton to construct the project (Sea 7044, Business and Professions
Code: Tha Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves muton,and who contracts for such projects with a
contramor(O licensed pursuant to the Contractor's License Law.
13 reason I em exempt under sec. ,e.sP,G.for mit APPLICATIONDATE VALUATION PERMIT EE
Owner Debq
WORKERS'COMPENSATION DECLARATION T aY ® Building"
I hereby affirm that I have a certificate of consent to self-insure,or a car r
tificaa of
Workers'Compensation Insurance,or a certified copy thereof(sec. �V Seismic
�
3800,Lab.CO. ` 16
Policy] No. Company //�� �J
h Certified copy is hereby with
th Cad. 0 199,E `�l Total
Certified copy is Watl with the city inspection division.
Applicant ��ll-' Lll
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
C ❑ P FIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred doL
Par.1d, or Im.)
I Certify that in the performance of the Work for which this permit is
owed, I sea: not employ any parson In any manner so n to become sublact
to chs Workari Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption.
Vv should become subject t. the Workers'Compensation provisions of the
Labor Coda, you must forthwith comply with such provisions or this permit
shall be deemed rwoked. All roofs shall be Inspected prlOrtO any roofing material being
l certify that I hay.read this application and state that the above informa installed If a roof is installed without first obtaining an
bon o correct 1 aorea a comply with en city and county ordinances and inspeoti0 I8gr8etOre V8811n vymaterialgforingpection
atop laws ,ebony to build Ing
thetr.cuon, and hereby wthoriee npresw �/
pulpa of this city to anter upon the above"mentioned property for inspection
pur(We) /V��j
(We)l aorto s, save, indemnify costs
and keep harmless which may
City of Cupertino
against liabilities,judgments,[Oats and expanses which they in any Way sttrue
' atoms Wes City.n<om«.ance of the.ranting m this permit. SIGNATURE OF 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