R-4041 PERMIT 4041
APPLICATION FOR CITY OF CUPERTINO NUMBER R�
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT PERMIT EXPIRES IF WORK IS NOT STARTED
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
A, �r BUILDING USE
-{��''Ry 0— `xxs � RESIDENTIAL COMMERCIAL OTHER
WNER'S
A100
��11 ` 1 HAZARDOUS ROOF
NAME 0V A An\xSf a�a4 NJ I &q FIRE •I���..,tt COVERING
{Q 1 AREA V CLASS
ADDRESS] SUOA-OC w e C,)- ��3 EXISTING ROOF COVERING
PHON 0TJ �- ,�j�� b �Q.� �0I tZ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S _
5 /1 Ov/_ ^ /1 r C TO BE REMOVED TO BE RETAINED
NAME LC-\.l 1 1 P f, /'1 J�/S TYPE40F ROOF COVERING
ADDRES
CIT&ZIPP O� 7�' ��+ ILS�C S a0 L.J S 9PI LEXISTI
PHOf(eO�6j�i -/ 7 1-1 7 UILT-UP ROOF
LICENSE ASP LT SHINGLES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 em licensed under provisions Of Chapter 9(common
cine with section 7000) of Division a of the Business and Profession.Cod., WOOD SHINGLES
and my ftim.' lu IDI a end affect. O
D...LiceGeae � Contractor
D �Ae OTHER (SPECIFY)
Date Ii1 Convector
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor'. License Lew for PRGP
the following reason. (Sec. 7031.5. Business end Profession.Cods Any city
Or count, which requires a permit to construct. alter, improve, demalish,Or
repair any structure, prior to its issuance, also requires the applicant for such
Permit to fila a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Lew (Chapter 9 (commencing with Section 7000)
' of Division 0 of the Business and Professions Code)or that he is exempt thereMINGLE
from and the basis for the alleged exemption. Any vitiation of Section
TO.T1.5 by env applicant for a permit subjects the applicant t0 a civil penalty
of not mora that rave nwnd.ad dollen( 500).1: eD AKE$
❑ 1,es Owner of the property.or my employees with wages as their tole
compensation,will do the work,and the structure is not intended Or offered
for sale (Sec. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
Lew does not apply to an owner of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that
such Improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
builder will have the burden OI proving that he did not build or improve for
purpose of.ale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, as Owner of the property, am exclusively connecting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: Tha Contractor's License Law does not apply t0 an owner of property PROVWE MFGR. INSTALLATION SPECS.
wn0 builds or improve.theraun, and who contracts for such projects With a N
convactor(O licensed pursuant to the Contractor's License Law.
❑ 1 em exempt under Sec. ,B.&P.C.for this
reason PP TION 0AY91 VALUATION PERMIT FEE
Owner Data is
WORKERS'COMPENSATION DECLARATION / �4
I hereby affirm that I neve a certificate 1 consent to sell-ins e,or a car / Building
oficeH of Workeri ComOpgn.�tion Insyrenu�`-c_ervfi opv t?areof(Sec. YfJ�`./�� 99� $eIBmIC
Policy Nom.V +s13 company
/1PD�s�MY1 {•• V E{�
8 CinvIi�ed copy is hereby furnished. s T/Np f� Lvi Total
Cert�Ilgl+cooY,tis tied yl?,v�ma city map cUm division. �i
Applicant(� f�L TP — N
CERTIFICATE OF EXEMPTION FROM WORKERS' N D ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dab
len($100)Or h as.) 41;*I certify that in the performance OI the work for which this permit i.
itluad. I shall not employ any person in any manner 40 at t0 become subject
to me Workers"C' Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you should become subject to the Workers' Compensation provisions of the
Labor Code, vow must forthwith comply with such provisions or this permit All roofs shall be inspec d prior to any roofing material being
.hall be d»med rwoked.
I certify that I have read this application and state that the above informs installed If a roof I in tailed without first obtaining an
bon is correct. I .v.» to =amply with .n city and =aunty ordin.nw..ata i0ldlOA'l
ion,I agree to re ov all new materials for inspection.
abte laws relating t0 building construction, and hereby autho roe ril"asam
turves of this city m enter upon me above mentioned property for inspection
pu rpows. `
(We) agree s, save, indemnify and keep es which
may
City of Cupertino against liabilities, corse sae.costs and ripens» fti is erY in mY w».=true
.wino said Ciw in con»qu»ce of the gramme oe snit permit LME 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