R-4064 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4064
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
130 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
O �1J RESIDENTIAL COMMERCIAL OTHER
OWNER'S ,��
NAME ///!1 �i /A FIREARDOUS ROOF
COVERING
AREA A- CLASS
ADDRESS 2 0l7-I ��C-��w � EXISTING ROOF COVERING
PHONE — NUMBER OF EXISTING COVERINGS f
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME �.v�.,i_,tfC--e �/�� —+;6��1� TYME OF ROOF COVERING
ADDRESS /J/y
CITY&ZIP Z Gy'l Gq�rlr..7 i , -41 EXISTING
PHONE �/3� Z��P-7_�f BUILT-UP ROOF
LICENSE r 6 AS T SHINGLES \
NUMBER 17 WOOD SH
LI CENSEO CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provision•of Chapter 9(commeo-
PIP. With Section TOM) of Division 3 of the Business andrProfessions Code. WOOD SHINGLE
and my license is in II f end effect.
License Cl - Lic.Numbe,SQ- y
Da. %v — Consrxmr OTHER (SPECIFY y�
OWNER BUILDER DECLARATION �y ` /
1 hereby affirm that I am exempt from the Contractor's License Lew for PROPOSED ` \
the following nems. (Sec. 7031.5. Business and Professions Code: Any city
or county wit
ich requires a permit to construct, alter, Improve, demolish,or
rapatr any structure, prior to its issuance, also requires the applicant for•uch BUILT- OOF
permit to ill*a signed statement that he is licensed pursuant to the provision• j /
of the Contractor• License Law (Chapter 9 (commencing with Section 7000) 1
Of Division 3 of the Business and Professions Code)or that he is exempt more ASPHALT$HINGL
from and the basis for the alleged exemption. Any violation of Section
7031.8 by any applicant for a permitubjects the applicant to a civil penalty
of not more that five hundred dollars($500).): WOOD SHAKES
I, as owner of the property, or my employees with wages as their sole
compensation,will do the work, and the structure is not intended or offered
to'
•ale (Sec. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
Law does not apply to an owner 01 property who builds or improves thereon,
and who does such work himself or through his own employees,provided that
such improverrients are not intended or offered for sale, If, however, the• OTHER (SPECIFY)
building or improvement is sold within one year of completion, me owner
builder will have the burden of proving that he did not build Or improve for
purpose Of sale')' PROVIDE I.C.B.O. REPORT NO.
D I, as owner of ma property, am exclusively contracting with licensed
contractorsto construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds of improves meroun, and who contracts for such projects with a
contractor(s)licensed pursuant to the Contractor's License Law.
p I am exempt under Sec. ,B.b P.C.for his
reason PPLICATION DATE VALUATION PER!PT FEE
Owner Oen
WORKERS
'COMPENSATION DECLARATION �/� L �O BUlldln r
N.of affirm that have i Certificate , consent to sal Lin core, o a cer' r
30ceta of Worker,'Compensmion Insurance,or a certified copv coarsest ISec. $eI3mIC
330Q Lab.C.I. f�.
Policy No. Company nn
8
Certified Copy i•hereby eu. had. LGFr 9YIP ( y�� Total
CeaiO pv is coed wit
he city insonation division. `�tv
A Pliant41 -
CE IFICAT O EXEMPTION FROM WORKERS' N C ERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed it the permit is for one huh red tl 4/�f
tan IS10 ifor Iat i la[�J`// ��
I certify thot in the performance of the work for which this permit is J
iasoad, I •hell not employ any person In any manner s0 s•to become subject
to the Workeri Comp rnootion Laws of California,n
Date Applicant
NOTICE TO APPLICANT: If, star making this Certificate of Exemption,
you should become subject to the Workeri Compensation provisions of the
Labor Code,you must forthwith comply with such provisions or this permit All roofs shall be inspected prior roofing material barn
.eau be doomed revoked. P P Y g g
I certify mat I nava reed cors epPlicstion and tiara mat the above inform•. Installed. If a roof IS installed without first obtaining an
tion is correct, 1 agree 10 comply With all city and county ordinances and inspection,I agree for oveall new materials for inspection.
state laws relating to building construction, and hereby autbori is represem
tetivo of this city to enter upon the abovementioned property for inspection
Purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino
: ins,liabilities,judgments,costs and expanses which may in any W:Y accrue ? ��
pa
:wins,said City in consequence of the granting of this permit., SURE-I APPLICANT DATE
AOL
WowPRE-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 i�