R-4219 PERMIT R, 4 219
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT.228 WITHIN 1180 DAYS OF PERM T�SUANCETOR
180 DAYS FROM LAST CALLED INSPECTION.
. BUILDING ADDRESS BUILDING USE
si, RESIDENTIALIL COMMERCIAL OTHER
OWNER'S HAZ�f 1air
N /,/.� �N FIREAR DOU ROOF
COVERING
AME
AREA CLASS
ADDRESS D fs-� / G EXISTING ROOF COVERING
PHONE OB C,257 6 it, ,?`7 ,'NUMBER OF EXISTING CO RINGS
CONTRACTOR'S
NAME TO BE REMOVED TO BE RETAINED
E OF ROOF COVERING
TY
ADDRESS
CITY&ZIP 1`7 EXISTING
PHONE�y�� 7 r el / 7 BUILT-UP ROOF
NLICENSEUMBER 3x0 ASPHALT SHINGLES
WOOD SHAKES v
LICENSED CONTRACTORS DECLARATION
1 hoebv affirm that 1 em licensed under Provisions of chapter 9(common-
eing with Section 7000) of Division 3 of the Business and Professions Code, WOOD SHINGLES
nd my license is in fun force and effect.
License Claes Lie.Number
Data Contractor OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I h...by affirm mat I am exempt from the Contractors License Law for PROPOSED
the following reason. (Sec. 7031.5. Business and Profession.Code: Any City
Or county which requires a permit t0 construct, alb., improve,Corti
repair any structure, prior to its issuance,also requires the applicant for such BUILT-UP ROOF
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)
of Division 3 of the Business and Professions Code)or that he is exempt there' ASPHALT SHINGLES
• from and the basis for In. alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more that five hundred dollars($50O). : WOOD SHAKES
❑ 1,as owner of me property,or my employees with wages as tnab sola
compensation,will do the work, and the structure is not intended or offered WOOD SHINGLES / s
for sale (Sec. 704 r4, Business end Professions Code: The Contractor's License
Lew does not apply to an owner of property who builds or improve$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) ryU/°. 7 ..
building or improvement is sold within one year of compbtion, the owner. ^/'L
builder will have the burden of proving that he did not build or improve for c
purpose o�sown. PROVIDE I.C.B.O. REPORT NO!- 9915
❑ 1, f owner of ma property, t ( ec. 7 44, convecting with licensee
omrectoss to construct ma project (Sec. 7044, Business and Professions code: ThaContractor's Llcen$. Lawdue,no,apply benowner ofp.op.rtY PROVIDE fill INSTALLATION SPEdSV(,,l
who builds or improves thersun,and who contracts for such Projects with a
contractors)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. ,B.&P.C.for this
reason APPLICATION DATE VALUATION PERMIT FEE
owner Data
WORKERS'COMPENSATION DECLARATION Buildin
1 habby affirm that have a certificate of consent to self n insure,or a ca
ti ticata of Work.,.Compensation imu.ance.or acartifi.d Copy thereof(Sac. (q�.cvv Salami
3800,Lob.G). x j y 0
Policy No. Company /7 / -/ V
8 Certified copy is hereby turnlmed. / ( Total
Certified copy is tiled with me city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N C PERMIT AUTHORI DATE
COMPENSATION I NSURANCE
(This section need not be Corti if me permit if for one hundred not
I...($100)0.Ims.)
I cattily to at 'm tn. performance Of the work for which this permit is
ibued, I shell not employ any person In any manner t0 as t0 become subject
t0 the Workers Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you should become Subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit A �shallbeinspectedprlortoanyroofing material being
shall be domed revoked.
1 Ttif, that I have .ad this.pplic.don and.1.1.sun m.abov.Informs stalled• If a lOOf is Installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinances and (OS PBC R I agr to rem all new Leri for inspection.
state law. tabun, to building con.vuction, and retain, authorize .epresem
fig
btives of this city to enter upon the above mentioned property for inspection
purposes. '
lW.l spree to awe, indemnify and bap harmless the City of Cupertino against liabilities,Judgment.,cos,.and..pan...which may in any waY¢true
.wino said City in consequence of the granting of this permit. R O I A T DAT
-� 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 _