R-4122 PERMIT R_ 412 2
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERMIT INSPECTION DIVISION PERM PERMIT EXPIRATION
(408) 252-4505 EXT. 228WITRI N OT STARTED
180 DAYS OF ERMIT XPIRES IF WORK TISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING DRESS - BUILDING USE
y 06.11
r RESIDENTIALI�COMMERCIAL OTHER
OWNER'S
/e` HAZARDOUS ROOF
NAME ` V`LCV\Q ��CY�r 2�� FIRE AREA CLASS COVERING
ADDRESS r�9r QP�I U EXISTING ROOF COVERING
PHONE �- 0NUMBER OF EXISTING COVERINGS /
CONTR CTOR'S
TO BE REMOVED� TO BE RETAINED �—
NAME TYPE OF ROOF COVERING
CI
ADDRESS p •^�' �-• ISTING
PHONE77� 03 C�2 BUILT-UP ROOF
LICENSE J ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSEDm the, C CONTRACTORS under DECLARATION
1 hooey affirm 7000) of licensed under provision OI dChapterProfessions
s(nommen
cine with Sec tion 7000) of Division ] of the Business end Protassiom Cod., WOOD SHINGLES
and my license ie In 1.44oc..rd eff•CL
Af
License Cless Lia.Numbs O '
Dan 117
Comracn OTHER (SPECIFY) P
NER BUILDER DECLA
I If affirm the, I am exempt fight the Contractor's License Lew for PROPOSED
the following reason. (Sec. 703 1.5, Business and Profession•Cod.: Any city JU� 30 1995
or county which requires a permit to construct,alter, improve, demoli•h,or
repair any structure,Prior to it.issuance, also requires the applicant for such BUILT-UP ROOF
permit to NIB a signed statement that he is licensed pursuant to the provitions
of theContractor's License Lew (Chapter 9 (commencing wish S.ceiop7000) Clly ur Wt'Cr%IINU
of Division i of tn.Busih.ss and Profession•Cod.)or that he is...,of mer. ASPHALT SHINGLES
• from and the basis for the alleged exemption. Any violation of Section
of To by any ,five hu for a p.rmd ubi.as me eoprpmt m.civil penalty yy00D SHAKE$ Ll >
OI not more twee five hundred property,
r my e.1',
❑ I, ti owner of m%progeny,o he employees with wends as weir sole
compensation,will do the work, and Professions
structureCodis not intended Le
for sola no apply
Business em PrrNlOns Coda: The Contractor's thereon.License WOOD SHINGLES
Lew does not apply to an owner o1 hr property who n em to improves thereon,
and who tloes such work himself or through his own employees,provided that
such improvemenm• ars not intended or offered for sale. If„however, the OTHER (SPECIFY)
building o. improvement is •old within one year of = mpletion, the o
builder will neve me burden of proving that he did not build or improve nfor
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am exclusively contracting with licensed
contractors to construct he project (Sec. 7044, Business and Professions
Code: The Contractor's License Low does not apply to anowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who contracts for such project,with e
contractors)licensed pursuant to the Contractor's License Lew.
❑ 1 .m exempt under sec. ,a.eP.c.foe his
arson APPLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I have a certificate of consent to selhinsure,ora cep 4 �/ /t ��� r.`^
tificat.01 Work%/' ir4p!•�iI In}ulance,or gCertified cgoy thereof(Sec, �'v /� (dL/LJ�J �/v Seismic
3600, Lob.C.1. bk.� !' _. 1 / _�
Policy No. Com Dann liG�.` `A '�y
pp c.��.C,) coor i.n.r.br mrni.n.d. Total
@�C."I fad coor i,filed.,in mi City inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N D ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This taction need not be completed if the permit is for One hundred d01
tar.($100)Or IMs.)
I Certify that in the performance of the work for which anis permit 1, 4
issued, 1 Shell not employ any porton in any manner so as to become subject
10 the Work.,.Compensation Lew.01 Cel'If Ornie.
Data Applicant
NOTICE TO APPLICANT: If, after making his Cereificat%of Exemption,
you should become subject t0 the Worked Compensation provi•1Ons Of [fie r
Labor Code,y.. must forthwith comply with Such provisions or this permit
.hall be deemed revoked. All roots shall be inspected prior to any roofing material being
I certify that 1 neve rand this application and state that the above informs Installed If a roof IS Installed without first obtaining an
non i. correct. I agree to comply with all city and county ordinances and I ;Ef�moyeater ialsforinspection.
Nee fews hisrelatingty to enter
construction, entl hereby aumorir spresm
tetiees of this city to mor u0on the aabovebode inept hetl byProperty for inspection
pw(We) - / � h�
(We)l apse to save, indemnify costs
and keep harmless the City Of.-, ___no ✓A.�e/l
against liabilities, cense see con end•x rating which they in any war.caw
.paint sera ctry in conegpmu of me greening of this permit. IG ATU OF APPLICANT
. 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
- I
I
I
Citsj of CNrertino
SMOKE DETECTOR CERTIFICATE OF COMPLIANCE
1 understand and comply with Section 1210-a of the Uniform Building Code.
Section 1210-a requires when repairs to a single family dwelling exceed $1,000, a smoke
detector will be installed, mounted on the ceiling or wall in each sleeping room and at a
point centrally located in the corridor or area giving access to room used' for sleeping
purposes. If existing smoke detectors comply, no new detector shall be required.
I understand the above requirement and certify that we now have smoke detectors
installed that do comply.
ADDRESS: lZ
PERNUT NUMBER:
HOMEOWNERS SIGNATURE:
DATE:
I
winword/smkdet
I