R-4411 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMB R R- 4 411
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 I III t1 (y ��1 L4ND. BUILDING USE
SCJ RESIDENTIAL COMMERCIAL OTHER
OWNER'S
dN N a .TI t�• HAZARDOUS ROOF
NAME FIRE COVERING
L AREA CLASS
ADDRESS y (.02Cn ' ' � -AND' EXISTING ROOF COVERING
PHONE
ZSS --7071
^1 17 I 1r 0 NUMBER OF EXISTING COVERINGS
CONTRACTOR'
1/•1 r ^ fes' A 1 �j TO BE REMOVED TO BE RETAINED Q
NAME 1 • 1 �(�'TI->••GC-. lam• •u(�• TYPE OF ROOF COVERING
CIT&ZOO No(a`7 CROS Wy
E� rQ � EXISTING
PHONE 9" l q68) 2-OL5 —���— BUILT-UP ROOF y
LICENSE Q-7 G'O`B �1 �1r] ASPHALT SHINGLES 'T_4Z
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby offLICENSED
mit I of licansed under provisions of dChapterProse s ons(timinhon
cine with section 70001 force
Division 3 or the Business end Processions Code, WOOD SHINGLES
en0 my'!'ense i n�, loris and affect. ����
License Clan Lia Number /
40*q�
Data Ctimrapwr a� OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I neraby affirm met I am exempt nom the Contractor's License Lew for
mPROPOSED
e following reason. (Sec. 7031.5, Business end Professions Code: Any city
or county which rcqulres a permit to construct.alter, Improve, demolifn,or `
repair
acv atrTure, prior to its issuance, also requires the applicant fof fvcn BUILT-UP ROOF X
permit to ills a ei'a Li statement that tier licensed pursuant to the provisions �4MKo
of the Contractor• License Lew (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code)or that he is exempt there ASPHALT SHINGLES
from end the basis for the alleged exemption. Any violation of Section
]031.5 by any appbcaot for a permit subjects the applicant to e civil penalty
of not more that five hundred Colors 195001.1: WOOD SHAKES
❑ I,as owner of the property, Or my emplOyan with wages as their sole
compensation,will do the work, and the structure is not intended or offered
for sale(Sec. 7044. Business and Professions Code: The Contractor's License WOOD SHINGLES
Lew does not apply to an owner of property who builds or improve%thereon,
and who does Such work himself of through his Own employees,provided that
coffered for sole. If, however, the OTHER (SPECIFY)
such improvements are not intended o offe
building or improvement sold within one year of completion, the owner
builder will have the burden o1 provi np that he did not build or improve for
purpose of"le.) PROVIDE I.C.B.O. REPORT NO.
D 1, as
owner of the property, em exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractors License Law does not apply to an owner of Property pROVIDEMFGR. INSTALLATIONSPECS.
who builds or improves mereun, and who contracts for such projects with e
corrtrac foils)licensed Pursuant w me Convenor's License Lew.
❑ I .m exempt under sec. ,B.aP.c.for this APPLICATIONson DATE VALUATION PERMIT FEE
ow Det.
Owner WORKERS'COMPENSATION DECLARATION p I ® Building !4E
hereby affirm that have i n certificate of consent to**Ifcopy
cher or a car. %
of%cab of workers'Compensation Insurance,or ecertified coot tna.eoi(Sac. �� /SOeO $eISmIC
Polio.Lab.C.). �`�
Policy No. Company /`•�
eCertified copy I.hereby furnished. 9 RfCIT Total
Certified copy is filed with ins City Inspection division.
Applicant C1'ry .
1 CERTIFICATE OF EXEMPTION FROM WORKERS' N C ❑ � t/UIR6R IT,AUTHORIZATION DATE
COMPENSATION INSURANCE
ITMf section need not be completed if the permit is for one hundred dot
len 151001 or Ins.)
1 canny that in the performance o1 [M1a work for which this permit if
issued, I shell t employ any Person in any m to 3 t��b��cyyy subject
D the-im-4-4 n Applicant Lem Of Celiforn e _ l\
Data ZZ APOliwnt
NOTICE O APP II, eibr making this Certilicata of Exemption,
you should become subject to the Workers'Compensation provisions of the
Labor Coda, you mon forthwith comply with such provisions or this permit All rootsahall be Inspected rlortoa0 roofing material being
mel be deemedrevoked.estf P P Y g 9
I certify that I have read this application and stns that the above informs Installed If a roof is Installed without first obtaining an
fiat i. correct. torn w comply with .0 city and county orize.nca.and Inspection
'-'--"�/ re live all new materials for Inspection.
tion btu% reining to building ply with all and hereby dco Guth oriie renrnan
tatives of this city to enter upon the above mentioned property for inspection
Pwpans. 'J /I 9
(Wal ogree to fns, indemnify and keep harmless which the City of Cupertino [J'
against liabilities, consequence
cont andthe expenses f this they in my way¢cwt
•
against said CIry in conwouan<a of the granting of nib Dermic 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