R 4174 OMBERRalkRMIT
APPLICATION FOR CITY OF CUPERTINO 4174
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS n � BUILDING USE
2235jI 'Raa�onV✓l �Q�Lr� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZAR
OOF
NAME � Uh n FIRE
OU COVVE ING (j
LASS
ADDRESS2 �C� �w Y EXISTING ROOF COVERING
PHONE -' V J p- NUMBER OF EXISTING COVERINGS I
CONTRACT/OiR'S��//�� y�/. ,^,II oo,�Af �/y ;n/
NAME 1.-�W, L nC,• U&4 l CLI_ Y Q,C, �66 f. TO BE REMOVED TO BE RETAINED_
r1 TYPE OF ROOF COVERING
ADDRESS /�'
CITY St Zip �Q o- '�rn�_N ll✓1ceA, / 'n 600 EXISTING
PHONE�1f�1 f 4— ��i(4 + Ll BUILT-UP ROOF
LICENSE (� SPHALT SHINGLES
NUMBER _I WOOD SHAKES I LGA-3P,�•
LICENSED CONTRACTORS DECLARATION �—
I hereby affirm that I em licensed under provblpns o1 Chapter 8 Icommem
cing with Section )0001 of Division 3 of Me Business;and ProthWons Code, WOOD SHINGLES
and my license p in is and*,fact.
Lions*Cb s Lic.Number
Orta Contractor H R (SPECIFY)
OWNER-BUILOER DECLARATION f11.
I hanby affirm that 1 em exempt from the Contractor's Licaned Lew for ' PRO ED I
the following noon. (Sec. ]031.8, Busmen and Professions Code: Any city - •+ '
or county which requires a permit to construct,sitar,Improve, d*moll$h,or
repair any structure.Prior to Its issuance, also required the applicant for such BUILT- R00
permit to fila a signed statement that he is licensed pursuant to the provisions 1/
FVO
of Me Contractor's License Lew (Chapter 9 (commencing with Section 9000) U
of Division 3 of the Business and Professions Code)or that he is exempt then. _
from end tna basis for the alleged exemption. Any violation of Section 1p ASPHALT SHINGLES 9.4s
7031.5 by any applicant for a permit subjects M•applicant to•civil penalty V I f Vl- L
of not more that five hundr.d doll...($500).): ODD SHAKES
❑ I,as owner o1 the Property, or my employees with wages as their tole
eompanubon,will do the work, and the structure N not incenses or L1f*nd OD SHINGLES for ole(Sec. 7044, Business usins and Professions Coca:Code: Th.CPntrector's Licena
5
Law 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 /� I_'o
such imDrovemenss are not intended or offered for $ale, 11, however, the OTHER (SPECIFY) 29 1 nroV`a Sf 1 -L2.-
building or improvement is sold within one year of completion, the owner
builcar will have the burden of proving that he did not build or improve for ''I
pPrpo$e p�$ale.l. PROVIDE I.C.B.O. REPORT NO. 4 ` 9.55
❑ I, s owner of the Property. a xUmivly convening with licensed
con[racton to construct the project (Sec. 7044, Business and Professions
code: The Contractor's License Low does no,apply to an own•,of property PROVIDE MFGR. INSTALLATION SPECS.
who build$ or improves thereun, and who contracts for such Projects with a
convector(.)licensed Pursuant to the Contractor's License Lew.
raa0 1 am exempt under Sec. ,B.&P.C.for this
owner Data APPLICATION DATE VALUATION PERMIT FE
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I have a certificate of consent to selldn sere,or a car <D
tific.n of Workers'Compensation Incur c or a cacti fled copy thereof(Sec. I I -J Seismic
380Q Lab,14 /�Cc .jam �9
Policy o. 11.11 _16"7-q C.mpenv 1Y� �U 11.)D
Certified copy is hereby furnished. Total
Grtifiad copy it filed with the city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMITAUTHORIZATION DATE
COMPENSATION INSURANCE N.C.
(This section need not be completed it the permit is for one hundred tlol �\ I 24iI /
Ins($10This s or I".)
I certify that in Me performance of Me work for which this permit is
nsuad. I shall not employ any person in any manner so as to become subject
to the Workers'Compensation Laws of California.
Deb Applicant
NOTICE TO APPLICANT: If, after making this Certifies,.of E.*mph.n,
you Mould become subject to the Workers' Compensation provisions of the
Labor Coda, you mutt forthwith comply with such provisions or this permit All roofs shall be Ina
shall be deemed revoked. pectedprlortoany roofing materialbeing
I certify that I have reed this application and state that the above informs Installed. If a roof Is Installed without first obtaining an
tion is correct. I ogres to comply with all city and couy ordinances and Inspect r I reetoremoveall new materials for l s ecti0 .
state laws relating to building construction, and hereby authorize presen P g p
,Byes of this city to enter upon the*Dove-mentioned property for Inspection
Purposes.
(W.) agree to say., indemnify and keep barmleed the City of Cupertino "2 `�/�
against liabilities,judgments,coats and expenses which may In any way accrue /
against said City in consequence o1 the granting of this permit. SIGN)MAlfD APP A T DTE
I PRE-INSPECTION: PLYWOOD: IN-PR REBS:
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 rnPY