Loading...
R-4063 (2) Is e PERMIT 4063APPLICATION FOR CITY OF CUPERTINO NUMBER R 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 190 DAYS FROM LAST CALLED INSPECTION, BUILDING ADDRESS Lt BUILDING USE Q�.f4zat • 1NOO� RESIDENTIAL COMMERCIAL OTHER OWNER'SS�y �J /' ROOF NAME 6ftL•a' A-4owAiii .5u4&ERLA^a4 FIRE HAZARDOUS . CLASSCOVERING ARE � ADDRESS as Z Q�Z�'f�'JWo�• E{`�X.ISITING .ROOF COVERING PHONE 252.— 3739' NUMBER OF EXISTING COVERINGS Z CONTRACTOR'S 1.AI�r��S i7� til TOBEREMOVED� TOBERETAINEO NAME w 1 /�F���T TYPE OF ROOF COVERING CITY&ZIP Q10G31 4 Us 011islai S Will Su tI�•�o• EXISTING PHONE 1944- 9+f f4 — BUILT-UP ROOF LICENSE471L/Off /7y ply ASPHALT SHINGLES ZO Y_ !�t��►T� NUMBER 7 WOOD SHAKES LICENSED CONTRACTORS DECLARATION I he,",affirm that I am licensed under provisions o1 Chapur 9(common ino with Section TOM) o1 Division 3 of the Business and PProf , WOOD SHINGLES and Lic nu C�anu is II�Y•mme end eifec Llc Number Iar asslo7 ns Coda qA Dere "OWNER W CDECLAR OTHER (SPECIFY) Oat I am UILDERexempt f om the Co ION nanbn reason. eam tort . 431.5, trim shed Professions rofe corn Code; Law for PROPOSED the following nn req (Sec. permit, o construct,ane Pilar, i pr Codd. Any city re coo my whlct re, ulna • permit a0 , alsorealter, improve, tlemor suc r repair any at...go, prior ro its issuance,he i also sed ires,Pur that to for such BUILT-UP ROOF P=it the to foe t signed statemLicense Law mea he is licensed pursuant it the tionprovisions00) 01 Ma Contractor's of the Licemo Lew (Chesser Professions I ode)of that wi aM1 Section)0001 75�cu ELIC , IC fr Division 3 of the efor th one gedexmtion, o.snot he is enols[thee.' ASPHALT SHINGLES �eepe. f YL 7031 and the baste lot me alleged exemption, Any violation of section of of by any ,five hundred for a permit subjects ma applicant[o a civil penalty of not more mat five themed property, 15y em WOOD SHAKES P A 1 0 ❑ I,n owner OI ma p.o rk, e o he employees with wages es[Hair sola compenution,will do the work, endthe structure is not intended or ollars0 for gala (Sec. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES pp Lew does not apply to an owner of property who build%or improves thereon, MIeY 1999 and who does such work himself or through his own employees,provided that such improvements are not intended o offered for sale. If, however, the OTHER (SPECIFY) building or improvement is sold within or year of completion, the owner /�I f1 builder will have he burden o1 proving that he did not build or improve for CI' F �( HTINO purpose Os sale.). PROVIDE I.C.B.O. POR W&. ❑ I, r of In. property. exclusively contracting with licensed contractors to c nstruct the project (Sac. 7044, Business and Professions Code: The Contractor's License Law doe,net apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS. wh0 builds or improves thereon, and who contracts for such projects with a contractorls)licensed pursuant to the Contractor's License Law. ❑ am exempt under sap. ,B.aP.c,for thisnuneon APPLICATION DATE VALUATION PERMIT FEE Owner Deu WORKERS'COMPENSATION DECLARATION Building I hereby affirm that I have a certificate of cnent to self Insure.or a car of iceb Leof Work., Compensation Insurance,or acartified copy Itareof(Sea /��/a ► SQISmIC 3800, o.C.I. 'I 7� 31 SOO Policy No. Company 8 Certified copy is hereby furnished. . Caroliso Total copy is filed with the city inspection division. Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. D ❑ PERMIT AUTHORIZATION DATE COMPENSATION INSURANCE (This Certify section need not er completed o if airkpermitisforone his per OOL a /r fan($100)Or IesL) 1 certify Inst in me performance o1 the work for which this permit if issued, I s ell 0a employ +nV Peno� iry� p 4140 of to become subject to ane motion Lews Qf C� (p/Iln Den Applicant L(/•^ NOTIC T APPLICANT: 11, eltor 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 ins acted rlortoan roofing material belt ah.l1 be deemed .vokad. P P Y g g I certify that I have read this pplica•ion end luta that the above informs installed If a roof is installed without first obtaining an Hon is correct. 1 Born to comply with .n City and county ordinances and inspection,I agree to removeall new materialsfor inspection. nate lewd relating to enter no the ab above-mentioned • d hereby wtnod7o nprmn. P rl1 g del�— P purposes.of anis city to mbr upon the above mentioned property for inspection s Pur we) ::tolA we)liabilities.agrn to save, indemnify and keep esharmlesswhich the City of Ch acting �7 7 against id ityi consequence con one oxPmnf which they in my way actions against city in connaumpe of the granting of this oermie 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