R-3842 (2) PERMIT R- 3842
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES 1F WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRES/S BUILDING USE
0�� V ��✓� �/ f RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS 1/Zj/�J ROOF
NAME U'"iI�' H'O��NO'AK mn4) AING
REA `� CLASS
ADDRESS N9 VvesAr r<^ f�r S} EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
� I,,. „ f��P\, _ TO BE REMOVED TO BE RETAINED
NAME ITI�'Y�—•� L /�F'I^'yt TYPE OF ROOF COVERING
NAME—
ADDRESS, � �S l�""T 7�" �s I �y EXISTING XC � (( j BUILT-UP ROOF
PHONE
LICENSE L] ASPHALT SHINGLES
NUMBER VL J Vt
WOOD SHAKES
LICENSED CONTRACTORS undo, DECLARATION
I nvwy storm 7000 1 of Division
3 of t provisions of Chapter s(co an
clop with Section)poo) of Dmi+ion 3 of me aaa;n-s ypd Pmiassiom codecoag, WOOD SHINGLES
sur my license i in I orc•antl afi•ct. L' 1 r"
Lice nw u Lic.Number O
D.t. connacto. OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm In at I am exempt from the Contrectort License Law for PROPOSED
the following reason. (Sac. 7031.5, Business and Professions Coca: Any city
county which requires a permit to construct,alter,.improve, demoll+h,or
repair any structure,prior to in issuance,also requires he applicant for such BUILT-UP ROOF
Permit to file a signed statement that he is licensed pursuant to the provisions
of theDiv Contractor's License law (Chapter g (commencing with Section I7000)
n.,.
from
Division 3 0l me Business and Prolusions Coda)or y vb.tion of
mate- ASPHALT SHINGLES
7031 end the basis for the alleged exemption,tthe
Any violation on of Section
)031.8 by any applicant In fora permit subjects the applicant to•civil penalty
of not more tym five nunmatl soder+(my em WOOD SHAKES
❑ I, ti ownsil of tube property,O he employees with wanes as their red
fom ale(S., will do the work.Profess structure Coda is not intended 's offLicense
for sale(Sec. )004, to an
and f property
Ootle: The or impr ve$ cacao+. WOOD SHINGLES
Law does not apply to en owner of property woo nemslo improve+thereon,
and who does such work not int or dorthrough his own employees.It,,however that
such ngo r improv are his intended within
o ne year
for tela. If, however, the OTHER (SPECIFY)
building or improvement th bur i+ seam within to a yet/ of completion,or, owner
builder will nova the burden of proving that he fir not built/or improve lor -
purpos.orsale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the property,am exclusively contracting with licenser
contractors to construct the project (Sec. 7000, Business and Professions
Core: The Contracto:sLicense Law does not apply toanowner ofproperty PROVIDEMFGR. INSTALLATIONSPECS.
Who builds or improves [hereon, and who contracts for such projects with s
contractor(a)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sac. ,B.a P.C.for suis FFLLCATION DATE VALUATION PERMIT FEE
own. Data
WORKERS'COMPENSATION DECLARATION Building
1 hereby affirm that I have a certificate of consent to self-insure,or a car
tificato of Workeri Compensation Inver or Us=e[If,dwQ7ppy mafaof(Sac. 51'001)
LI�7-• $eI3mIC
PO�cv No. 'LSI_CoVn pent V ,Y/ )I�� 3 '99C ./ I O� L
C".Red copy is ata by i atl. Ch(CJC
sjl Total
C tiff•d,,�oPv is 61 Wit h tY action division. ! UI L'UY
Applicant '�l/f 1
CER IFICATE OF EXEMPTION k0l WORKERS' N D PE •MIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(Thision our not be completed if the permit is for one hundred tloL j
bat 151001)or Its .)
nnfh tnat a ma performance of any
work s as which too a subject h
tothe I shall not amens, any pawn in my manner so n to become subject `J
to the Workers'COmpansetitln Laws of California.
Data Applicant
you ICEshould
ld APPLICANT: H, Mur making this Compensation
p of Exemption,the
Vote Labor Cod bacume tunjact i [ata Workmply w h such psation provisions a me
.hallcode, vppmoat forthwith comply palm such prom.mns o, this permit All roofs shall be inspected prlorto any roofing materialbeing
snail be tleemetl rwok•r.
I certify that 1 nave rear this Rpliicaeon err ante that the above iMorma Installed If a roof Is Installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinances and inspection,I agree to remove all new materials for inspection.
state laws .fail., to builtllnp con+trucbon, and Insist, author;.. ...reser.
tstive of this city to enter upon the abovementioned property for inspection
purpose+.
(W•I agree to save, indemnify and keep harmless the City of Cupertino4-1
ILK
against liabilities,judgments,costs and expenses which may in any way accrue
against said City in consaouence of the granting of this permit. SIGNATURE OF APPLICANT I 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