R 4036 OMBERROORMIT
APPLICATION FOR CITY of CUPERTINO '4036
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
ISO DAYS FROM LAST CALLED INSPECTION.
\
BUILDING
ADD
✓ yJ(/�DRESS c ILDING USE
\� ! U 5 1 V'o J e_c_,+ e RESIDENTIAL COMMERCIAL OTHER
Ik OWNER'S t n
YV �_ COVERING
Vv��V �� HAZARDOUS C) CLASS
tt� ROOF
NAME FIRE P
crJ
ADDRESS_�S o J f� EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS !
CONTRACTOR'S n S� .1'Q. � /�-(_J TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADDRESS
CITY&ZIP EXISTING
BUILT-UP ROOF A A
a _ PHONE_
*' LICE
NUMBERNSE ASPHALTSHINIGG19
LICENSED CONTRACTORS DECLARATION WOOD SHAKES!U!- UurC�1l1Y�
I hereby offirm the,1 am licensed under provisirn%of Chepl. 9(common
cin. with Section 7000) of Division 3 of the Business end Professions Coda, WOOD SHINGLES
and my license if �u race end effect. A
Dan = Contractor 2 OTHER (SPECIFY)
Dm Contractor
OWNER-BUILDER DECLARATION
I hereby affirm.
that I am exempt from the Contractor s License LOW for PROPOSED
the following reason. (Sec. 7031.8, Business and Professions Code: Any city
or county which requires • permit to construct. alter, improve, demolish,or
repair any structure,prior to Its Issuance,also requires the applicant for such BUILT-UP ROOF
permit to fila a the Business enmant that ha is licensee ou hath to exe provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) _1
fr m,and 3 of the forthand Proalleged
exam tion. or that he d•adopt them ASPHALT SHINGLES
7031 end the basis for the allermi exemption. Any ant to
o1 Sec Non
7031.8 by any that
hu fora pomp subjacn ma applicant[o°civil penalty
01 not mon twee five hundred artier($500).):em WOOD SHAKES
p ❑ I,ti owner of the property. Or he employees with wends of Noir area
\v-\ for 9 1*(Sec.
will e0 me work, and ess structure h not intended '.ollena yy00D SHINGLES
for sees(Sac. 7044, Business and PrProperty
o arty who
The r nvecmi s License
Lew does not apply o an owner of hr o through
who buildslo imp!oras merehat
and who does antuch work no, intelf or ed or offered hie own r Sol . If, howevetl son
such ngorr impros are not old wits or neyfor cola. If, hOthevo, the OTHER (SPECIFY)
builder. or improvement is at within one year of complete or ma owner
builder will have the burden of Dr Ovim.hot he tlitl not build or improve for
purpose era down PROVIDE I.C.B.O. REPORT N0.
❑ I.
owner of the property, exclusively contracting with licensed
cdnVecton to construct the gooiest (Sac. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who build% or improves thereon, and who contracts for such Projects with a
contractor(s)licensed pursuant to the Contractor's Licence Law.
❑ 1 .m exempt !neer Sac. ,e.aP.c.for this APPLICATION DATE VALUATION PERMI EE
meson
Owner Data
t WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I havee/a certificate of consent to self•inwre or a car.
policy
ry f Workg, O.�Pd7p nylnw!arca oL if ad 'J , pot(Sec. �S- ' ,v, / � C) S`aiemlCTZ �-
3800,Lab 1v1'orr'
A[Certified copy Ia hereby furnished. T0181
II Car .
Applicant
CERTIFICATE EXEMPTIONFRO WORKERS' N,C, O PERMIT AUTHORIZATION DATE
COM NSATION INSURANCE
(This Section need not be completed if the permit i%for one hundntl tl06 �\\ �� Q�/]7� /IS /y
ears 1001 or leaf.) `f 0 +
C I certify that in the performance of the work for which this Darmit is
issued.hI ma11 not employ any Lenon In any manner to n to become subject
t0 the Worker'Compensation Laws of Celifornis.
Do' Applicant
NOTICE TO APPLICANT: If, sitar making this Certificate of Exemption,
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 prior roofer materialbein
mass be deemed revoked. P P Y g g
I certify the, m
I have read this application end state that the above InforF Installed. If a roof Is Installed without first obtaining an
tion is correct. I agree to comply with ail city and county ordinances and
din a tioei I ego a 10 move all ere aterielaforinapeCtlon
f.tiv.of ela laws retailing t0 building construction, and hereby authorize reprssem
the%city to enter upon the above mentioned property for Inspection
purposes.
IWO) area to save, indemnify and keep harmless the City of Cupertino
against liabilities,judgments,costs and axpenreo which may in any way accrue SIGNATURE O PPLICANT DATE
O ria City in consequence of the granting of this Permit.
PRE-INSPECTION: PLYWOOD: N-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