R 4133 PERMIT 413 3
APPLICATION FOR CITY OF CUPERTINO NUMBER Res
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMITNOT
(408)252-4505 EXT. 228 WITHIN 1180 DAYS OF PERM T ISSUAN CE
IN DAYS FROM LAST CALLED INSPECTION.
. BUILDING ADDRESS BUILDING USE
RESIDENTIALCOMMERCIAL OTHER—
Owi
HAZROOF
yyy���G
N E _L_�l�a E�I9 //�/ FIREARDOUS COVERING C/�S P /1
AREA CLASS
ADD Ess_1072- S/i-n/Ta /,LJ XISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
l . 1Ga ner TO BE REMOVED TO BE RETAINED
NAME Vt�,� TYPE OF ROOF COVERING
CIITY aiS�6rS7Zy�jo(Q� �S Nome Sere"d 9b EXISTING
PHONE 7 Q3� BUILT-UP ROOF
LICENSEASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby Section
that I of 11I.hmcensed 3 of T e Busiom of Chapter
B Ibommee
a n0 wires Section 70001 of Dind If.3 of Ma Business and Profaulom coda, WOOD SHINGLES lO
end my Ilunu bjr.WldQfce and alfecc ��
Licen..Cleu �r ]`� Lic.Number OTHER (SPECIFY)
Oeu contractor
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor'. Lice... Lew for [ '
PROPOSED
the I0 flowing reason. (Sec. 7031.8, Business and Professions Coda: Any city
or county which requires a permit to construct, oho, improve,domolleh,or
lapel'any rtruc[we,prior to In Issuance,elm esquires the applicant for such BUILT-UP ROOF ., �,� 7
pomp to Iib•sighed statement that he is licensed Pursuant to the provisions
of Me Convector'.License Lew IC spur 9 (commencing wi,b Section 70001
of Di is on 3 0l the Susines end P, buiom Code)or that be is exempt there ASPHALT SHINGLES" V d
from and sine bests for [h eller xem. the AnY violation of Session Lr
7031,8 by mY aPPlita t to a Per it ublacls !ha applicant to•Civil Penalty
OI not more that liNdl
dd dol ra sero).): WOOD SHAKES
C3 I,as
owneroer y employees with wages as!heir sole
peneetlon,wilOr t'ructu re it not in tentletl m offaretlfor cele (Sec. 704een tions Code: The Contrector's offered WOOD SHINGLES
Lew eonnotappwer pr any who builtls or improves thereon, """""�"""" """""ang who tloes sucIf r In rough his own employees,provldetl,net Q rmotes Improveman intended or offeree for gale. U, however, the OTHER (SPECIFY) /-
buildinp or imprOvamant sold within one year of completion, the owner
builder will have the buret of proving that he did not build or improve for
P"'°°'°°feel°')' PROVIDE I.C.B.O. REPORT NO.
CI I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project ISec. 7044, Business and Professions
Code: Th e Contractor's License Low does not apply wmowner ofProperty PROVIDE MFGR. INSTALLATION SPECS.
who builds Or improves thereun,and Who contract.for such projects with a
contractor(s)licensed pursuant to the Comractor i License Law.
ree
pn onepnI em exempt ander sea ,B.aP.c.for this APPLICATION DATE VALUATION PERMIT EE
Owner Data
WORKERS-COMPENSATION DECLARATION ®� Building
I hereby affirm that I have a certificate of consent to call-insure,or a car A
,III.eta of Workers'Compensation insurance,or a certified !hereof(Sec. 00;r23 199 $eismlC
3800, Leb . ��f` �I F
Policy No��ompeny_5iQT2 u ,�f) C
Certified v Is Mnby fu sed. l/t J /(`�T Total
Cotifi < s filed witl�t t °action division. LL,./,
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. ❑ PERMIT AUTHORIZATION DATE
COMPENSATION I NS URANCE
(This section need not be completed it the permit is for one hundred dol /O
I...(f100)or lux.) 1L/ /
I certify that m the performance person of any
work for which this permit is
Huse, I shell not employ any person In any manner to as t0 become subject
to tn@ Workers'Compensation Laws of California.
Data NT:App1iM
NOTICE TO APPLICANT: o 'fur making this....li iceb o1 Exemption,
you moue eecome
sublet[ t0 the WOrkari CompemaiiOn provisions Of LM1B
Labor Coda,you must forthwith comply with such provisions or this permit All roofs shall be Inspected riertoan roofing materialbeing
shall be deemed nw.k@d, P P Y g g
1 Certify That I have read this application and state that the above Inform& Installed If a roof Is Installed without first obtaining an
lion is correct I ague to ng cons whn all city and bounty Ordlnmtas and Inspection,I agree to remove all new materials forlI s eCtio
smote laws 'ebony to enter
building construction,aboven, end hereby sex ty for npragan. P n� g 1J P`jr\
popes o1 this city to sung upon the abovementionad PrOpory for Impaction /// ./.(- •/l �0�+
Dwposas.
(We) agree to save, indemnify and keep harmless the City Of Cupertino
@rains,liabilities,Judgments,Costs and expanses which may in any way accrue
.'Bina Said City in consequence of the granting o1 this permit SIGNATURE OF APPLICANT DATE
. 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