R-4047 PERMIT R_ 4047
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
a 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �+ y/A�- BUILDING USE
6- 3 G V� RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME FIRE COVERING
G' AREA CLASS
ADDRESS vim/ G/L — EXISTING ROOF COVERING
PHONE �O Z NUMBER OF EXISTING COVERINGS
CONTRACTO ,
TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
n
CIDTDY&ZIP
EXISTING
PHONE 7 �(o 'Y"y BUILT-UP ROOF
LICENSE / C/ / ASPHALT SHINGLES
NUMBER CGO !G(O X
WOOD SHAKES
LICENSED CONTRACTORS under DECLARATION
I hereby affirm that I of Division
of t provisions of Chapter 9 Icommeo-
ting with Section T000l of Dimelnn D of ma e.athna and Pniemonec WOOD SHINGLES
and my Iicfm Is Io+uljaf end erect.
Lipnu C• Lim Lic.Number
Da. Co ;r ,nn OTHER (SPECIFY)
OWNER BUILDER DECLARATIO
I hereby affirm that I am exempt from the Convacto•'s License Lew for PROPOSED
the following roson. (Sec. )0]1.5, Business and Professions Code: Any city
or unto which requires a permit to construct, altar, improve, afmolish,or
open env struClues, prior to its issuance, also requires the applicant for such BUILT-UP ROOF
P. to ills a signed statement that he is licensed pursuant to the provisions
of the Contractor's Business
Lew roses,.Chapter B (commencing with Section t7000)
here
from
Div nd o of the afor the all ged exemption.
tion.l or aha he is exempt mer.. ASPHALT SHINGLES
from one the Dosis for the alleged exemption. Any violation of 5«tion
9081.5 by any tmppl favi fora permit 500).)s me applicant to a civil penalty
of not mon that fivetheprhundred muan(E5y em WOOD SHAKES
1, a o1 ma property,o he employees with wends as their sola
fom.I. (Sec.will do the work,Profess structure Code:
is not interface Contractor's offered WOOD SH INGLES
for tale ISec. TWA, 10 neo end Pf property Coda: The imprve thereon,Law does not apply toe of property who builds or improves[hereon,
and who don such work M1 mself or through his own employees,provided that
Such improvements . t
not intended o offered for sale. u, however, the OTHER (SPECIFY) 0, -
buildinn or improvement is sold within one year of completion, the o
builder will have the burden of proving that he did not build or impro error ��//
purpose of sale.). PROVIDE I.C.B.O. REPO RT NO. Z9 70
� 1, m owner or the property, em exclusively contracting with licensed
contactors to construct the project (Sec, YOAA, Busmen end Professions
Code: The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
Who builds or improves theraun, and who contracts for such projects with e
onv«tor(s)licensed pursuant to the Contractors License Lew.
C3 I .m ...mot and.. set. ,B.ay.c.for his APPLICATION DATE VALUATION PERMIT FEE
reason Dar.
ger WORKERS'COMPENSATION DECLARATION DO Building /CY
I herebyaffirm that 1 have a certificate of t to self insure. /p �/
hficne of N kari Cq tion Incur9p y� wi a copyem C:.o+fs.c. ,� �L $e15mIC 1.,410
0800, Lab
No. Mo G_OJ/ s / //{•••
Policy No. mpeny�OCe^CLC.(rW cw (a_� /��
Certiliee touts is leraby shad. P D Total l
qC
Ca rifieq�py�r(�iladw fMJ ci gac�i� cion.
Applicant �j( ( aL!
CERTIFI ATE OF EXEMPTION F�WORKERS' U
n 15IZATION DATE
COMPENSATION INSURANCE N•D. 0
(This section n«a not be completed if the permit is for on.hundred dol. 1 �Fy
aff
le1001 or Ine.l
1 Certify that In the performance of the work for which this permit is V CITY ,1I- GlLI PEKI INU
issued, I shell not employ any parson in any manner so as to become subject
V I
to the Workers Compensation Laws of California. OI► �M
Date Applicant
NOTICE TO APPLICANT: If, alter making this Certifiure of Enemprign,
you should become subject to the Workers' Compensation provisions of the
Labor Coda,you must forthwith Comply with such provisions or this permit All roofs shall be inspected prlortoeny roofing material being
shell be Claimed revoked.
I Certify that I have reed this application and state that the above Informa. Installed. If a roof is Installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinances endinspection lagras to remove all new materials for in action.
fate laws mating to building construction, and hereby authorize represem
.dives of this city to enter upon the above mentioned property for inspection
purposes.
(We) 41,011 t, uve, indemnify and keep hamlen me City or Cupertino
against
sold City•In consequencesofthe grantingsof finis permit.any coats eccrye SI ATUR 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