R-4158 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4158
REROOF PERMIT
INSPECTION DIVISION PERMIT E ORKI N
PERMIT 180 DES 1F WORK IS NOT STARTED
(408) 252-4505 EXT. 228 WITHIN80 DAS F DAMS OF PERMIT ISSUANCE OR
s 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS / BUILDING USE
InRESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME �� Ile r FIRE COVERING
p AREA CLASS
ADDRESS /-1— EXISTING ROOF COVERING
PHONE 0/J Q'r2 c+ - NUMBER OF EXISTING COVERINGS f
CONTRA OR's
l TO BE REMOVED v TO BE RETAINED
NAME + as ' TYPE OF ROOF COVERING
a CIT &Z10 V 1O EXISTING
PHONE s `� �S So BUILT-UP ROOF (�/J
LICENSE `35 -) 2 —3 ASPHALT SHINGLES �
NUMBER 6 WOOD SHAKES Y
LICENSED CONTRACTORS DECLARATION /6
hereby affirm that I of licensedion *1under e Business
of d Chapter (common III WOOD SHINGLES FC
clop with Sectiory)0001 of piv" H 3 01 Ma Businan e d Pr L ony CpEe,
and my license ifid/til antl allact �'L1 Y
Litenw Cbn Lic.Number ✓ fy
Dat. Contractor OTHER (SPECIFY)
OWNER.BUILDER DECLARATION
1 hereby affirm that 1 am e..mpt from the Con,..cm:• License Lew for PROPOSED
the following reason. (Sac. 7031.5, Business and Professions Code: Any city MAY 31 96
or county which requires a permit to construct, alter,Improve, demolian,or
rpair any structure,prior to its issuance,also requires the applicant for such BUILT-UP ROOF
Palm to 111.a signed aatement that he is licensed pursuant to the provision.
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) Ci 1 1 Vf UUi L.r l(IVU
oI Division 3 of the Businan no Probsuon.Code)or that he is exempt more ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of section
7031.5 by any appli<mt for a permit subjects the applicant to a c vii penalty
of not mora that five hundred dollen(9500).). WOOD SHAKES
C3 1.as o r of mr
a property,o my employees with we"$n their sole
compensation will do the work, and the structure is not intended or oHared WOOD SHINGLES
for sea (Sec. 7044, Business and Professions Code: The Contractor's License
Law don not apply to an owner of property who build.or improve thereon,
and who doe such work himself or through his own employees,Provided that
such impfovemenn are not intended or offered for +ale. If, however, the OTHER (SPECIFY)
builtling or improvement sole within one year of c mpleni n, the owner
builder will have the burden of proving that he did not build or improve for
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, • rof the property. • exclusively convalti.,witn licensed
pntractors to constn t the project ISec. 7044, Business and Professions 1^
Code: TheContractorYLicensoLowdoesnotapplytoanownerofproperty PROVIDE MFGR. INSTALLATION SPECS.
�O
who build$ or improves tnereun, and who contracts for such projects with a
contracmrla)licensee pursuant to the Comractor's License Law.
❑ 1 am exempt under Sec. ,B.&P.C.for this
APPLICATION DATE VALUATION PERMIT FEE
Owner Date
WOSICOMPENSATION
su n ION Building /5�7
1ahereby am that he•certificate of consent to self insure,or a car
tificn
o1 Workers oma ation Insurance,or cerNfy'�d copy thereof ISec. Seismic I19
3Ba0,L.b.c,I.W�(p I I�r)3��-5 �l�C I C;0 r>+1C) �- d O
Policy No. Day / Total
BCertified copy is hereby furnished. /
Certified copy i$filed with the city inspection division.
ADDlicant
CERTIFICATE OF EXEMPTIONFROM WORKERS' N C ❑ PERMIT AUTHORIZATION DATE
l COMPENSATION I N S URANCE
(This section need not be completed if the permit is for one hu ndrad dol.
lar$(f10010.Ie, i g�
I c100) that In the performance of the work for which this permit i Jor
issued, I Nall not employ any person in any manner fee as to become..bject
1fi to the Workers Compensation L.W.of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you should become subject to the Workers Compensation provisions of the
Labor Code,you must forthwith comply with such provisions or this permit All roofs shall be inspected prior toany roofing materiel being
.hell be deemed revoked.
I certify the I have read this application and stn.in.,In.above informs Installed If a roof is installed without first obtaining an
tion is correct. 1 agree to comply with all city and county ordinances and inspection,I agr to remove all new materials for inspection.
nee )awe relating to building construction, and hereby suthotixe repreem
tatives of this city to enter upon the above-mentioned property for inspection
purposes.
(We) agree to save, indemnity and keep harmless tM City of Cupertino
against liabilities,judgmeno,costs and expenses which may In any way accrue SIGNATURE OF APPLICANT DATE
."nal aid City in consequence of the granting of this permit.
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 isaaaa y __ __ _