R-4091Ll
C`.
0-
OFFICE COPY
PERMIT R_ 4091
APPLICATION FOR CIN OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)252-4505 EXT. 228 WITH;N 180 DAYS OF WORK
ISSUANETOR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDDREESSS'7'
BUILDING USE
^08->v /J �a lG� /LCG•+ ��r
RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZ
ARDOUS ROOF
NAME f'�/ g'+-�"�
FIRED COVERING
AREA CLASS
ADDRESS /t1/Clpg S o �C�/L7�.
EXISTING
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS ,
0C
yds 6
PHONE J i r+Z /
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S /J 1+
NAME �r SR -S !/<r+»1 i�.4
TYPE OF ROOF COVERING
�� 3�3p
CDDF&ZSF/✓\Ja
EXISTING
s
��✓�s�— Y� �{`
BUILT-UP ROOF
PHONE
SHINGLES
LICENSEASPHALT
y%%./tO �'
NUMBER
WOOD SHAKES rte_
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under Provisions of Chapter 9 (commons
ing with Section 7000) of Division 3 of the Business and ProfessionsCode,
and my license ii cul i d end affect.
�Q
WOOD SHINGLES
M e
MAY
License Clev Lic. Number ` o
Co'. Contractor
OTHER (SPECIFY)
OWNER -BUILDER DECLARATION
CITY Ur vUrcHIINU
I hereby affirm that I am exempt from the Contractor's License Lew for
PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Coda: Any city
which requires a Permit ,o construct. altar, improve, demolifh,Or
.paiun[y
r any structure, Prior to its issuance also require• the applicant for such
BUILT-UP ROOF
Dermlt to Ella a sipped alabmen, the[ he is licensed Pursuant to the Provisions
of the Contractors License Lew (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Profession, Code) or that he is exempt there
ASPHALT SHINGLES "
from and the. basis for sun. Ileyad exemption. Any violation of Section
' 7031.5 by any epplic ant fore Permit subjects the applicant to a civil penalty
of not mon that five hundred dollars (500).):
WOOD SHAKES
❑ I, as owner of the property, or my employees with wages as their sole
=om pan•etion, will do the work, and the structure if not intended or offered
for sale (Sec. 7044, Business end Professions Code: The Contractor's License
WOOD SHINGLES
Law don not apply to an owner of properly who builds or improves thereon,
and who does such work himself or through his own employees, provided that
not intended p offered for sale. U, however, the
such improvements a c
OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or Improve for
purpose of Sale.).
PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am exclusively contracting with licensee
contractors t0 construe, in. project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property
PROVIDE Ill INSTALLATION SPECS.
who builds of improves thereon, and who contracts for such projects with a
cum rectors) licensed pursuant to the Contractor's License Law.
❑ 1 em exempt under Sec. ,B.&P.C. Ins this
I
APPLICATION DATE
VALUATION
PERMIT FEE
Do,e
WORKERS' COMPENSATION DECLARATION
_
Building
, cometh to Copy th or a cer.
I hereby affirm that I have i n Insurance,
3800, o1 Workeri Compensation Insurance, or certified copy [rear/of (Sea
Policy Lab. CO.
�y
ld
/�
SaIamIC
Policy No. Company
Certified is hereby
GL
Total !�•
copy
with tcit'I
e D..bfi.d appy is kited withth.=imY inspection division.
MAY 1 7 199
Applicant
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. ❑
COM PENSATION I NS URANCE
(This section need not be complete! if the permit is for one hundred dol.
los ($1 r ins.)
certifyWhich
I ,na, in the performance of tats work for wb toss this permit if
ratify
intoe, 1 shah not employany Lenon in any manner +o as to become subject�Y
,o the Work.,.' Compensation Laws of California
Nate Applicant
NOTICE TO APPLICANNT::H,, atter making this of Exemption,
you should become subject the Workers' Compensation provisions the
p
a mit
must forthwith comply with .seen proYi.ipn, pr this permit
Labor i Suchprovisions
All roofs shall be inspected prlortoany roofing materiel being
dyoueemed
shell be .famed revokae.
installed. If roof is installed without first obtaining an
I certify the' I have reed this application and state that the.bove inform.
a
bon I. =pra=t. I agree to comply with oil city and county ordinances and
inspectio I agree to remove all new materials for inspection.
stab laws relating to connaboveq and hereby authorize apreum
nbuilding
s this cIIV to enter upon the above mentioned property Ipr inspection
Purposes.
pulp s.
(WI apiN 1.s. save, indemnify the City of
and keeexpenses
or ---ino--
apainn liabiliiias, judgments, cum pd ax Oanus which may in mY war accrue
l costs es which
pains, said City in consequence of the painting of ,his 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