R-4434OFFICE COPY
PERMIT
R- 4434
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT EXPIRES NOT
(408) 252-4505 EXT. 228 WIPERMIT IF WORK IS
180 DAYS OF PERMIT ISSUANCEOR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
- BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME
FIRE COVERING
AREA CLASS
OSg"rly
EXISTING ROOF COVERING
ADDRESS C_
0u/ce-„-V0j
NUMBER OF EXISTING COVERINGS
PHONE OEC
CONTRACTOR'S
6 `�<_�
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING_
NAME W •
RESS
CITY at ZIP
EXISTING
BUILT-UP ROOF
PHONE
ASPHALT SHINGLES
LICENSE
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
affirm that under provision of 9 om
I herwith
of ivi.iCd
..no Sohn enation T000l of Division 3 of mat Bgeinpe and Protepion n l
d Pn.fr
WOOD SHINGLES
and my is in full lora •r.0 •lfec t. _ /�/ ,.I
Cass
..P.Cass- Lic. Number[`j
erase Contractor
OTHER (SPECIFY)
OWNER -BUILDER DECLARATION
I hereby affirm that I am ...mss, from toe Contractor's License Law forPROPOSED
the following reason. (Sea. 7031.6, Business and Professions Coda: Any city
or county which requires a permit to construct, after, Improvm
, d•olisn,or
repair any structure, Prior to its issuance, also requires the applicant tot such
BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
o1 the Contractors License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code) or that he is exempt thele.
ASPHALT SHINGLES
from and the basis for the alleged eaamplion. Any violation of Section
7031.6 by any applicant for a permitubjects the applicant t0 a civil penalty
of not more that live hundred dollars (i6oO].L
WOOD SHAKES
❑ I, as r of the property, or my employees with wages as their Sole
compensation, will do the work, and the nuctur. is not intended a offered
r sole (Sec. 7044, Business and Professions Code: The Contractoit License
WOOD SHINGLES
Lew tlop not apply to an owner of property who builds or improves thereon,
and who dosuch work himself or through his awn employees, provided that
suchimProvements are not intended or offered for Sole. 11, however, the
OTHER (SPECIFY)
building or improvement is sold within one Yee, of completion, the owner
builder will have the burden of proving that he did nor build or improve for
purpose �iaele.).
PROVIDE I.C.B.O. REPORT NO.
❑ 1, s owner of the property. am exclusively contracting with licensed
contractor. to construct the Project (Sec. 7044, Business and Professions
Code: The Contractor 'sLicense Law does not apply toanowner ofproperty
PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves tnereun, and who contracts for such projects with a
contractor(s) licensed pursuant t4 the Contractor's License Law.
❑ 1 em cantle ,B.&P.C. for this
reason —
I ION DATE
VALUATION
PERMIT FEE
Owner Data a.
'FIKER COMPENSATION DECLARATION
Building”
h Neby a nm the, 1 have • ertilicate of consent t0 self insure, o, a car. A
.II^
��
tilicate of Workers' Compensation Insurance, Or anc•rtified copy thereof (Sec.
CU
(r (f
Sel$ml('iI
T'tv
3800, NoLabC.1. r)I
Policy No. Company
ttlLL
LVrLH
eCertified Copy Is
LINO
Total
filedherebyw th theM1ed. n
Certified copy is filen Sohn the city inspection dlvisio
Applicant
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. ❑
COMPENSATION I NB URANCE
(This section need not be completed it the permit is for One hundred do'.
I.ra IeI DDI or less.l
1 certify that in Me performance of inn work for which this permit is
issued, 1 shall not employ any parson in any manner so as to become subject
to the Workari 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 .1 In.
Labor Code, you must forthwith comply with such provisions or this permit
All roofs Shall be inspected to any roofing materiel being
hall be deemed revoked.
prior
I certify that I have had this application ane step met the above inlorme
Installed. If a roof is Installed without first obtaining an
tion is core t. I agree to comply with an city and county ordinances and
inspection, I agree to remove all new materials f rinspection.
at•.. lam lacing to building construction, and hereby authorize rapr.loh
,olives of this city to anter upon the above mentioned property for inspection
purposes.
(Wel •gree to save, indemnify and keep harmless the City of Cupertino
r�(
ageing liabilities, judgments, casts and expanses which may in any way accrue
ageing acid City in consequence of the granting of this Permit.
SIGNATU OF APPLICANT TE
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS:
INSP. DATE
INSP. DATE
INSP. DATE
TEAR OFF INSPECTION:
BATTENS:
FINAL
(NSP. DATE
INSP. DATE
INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY