R-3916 (2) PERMIT
APPLICATION FORCITY OF CUPERTINO NUMBER R- .3 916
REROOF PERMIT
It - '-INSPECTION DIVISION PERMIT EXPIRATION
(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 �e BUILDING USE
j O 1 ,1"l RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME / // .� AREA �� CLASS
COVERING
ADDRESS ii0/�. — ��11/i`� L—" EXISTING ROOFCOVE`RING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME S C TYPE OF ROOF COVERING
ADDRESS
CITY 81 SS �/2 Z ���� a EXISTING
PHONE 7 BUILT-UP ROO
LICENSE /'� 5� ASPHALT SHI GLES
NUMBER J WOOD SHA S
LICENSED CONTRACTORS DECLARATION
I hereby affirm her I am licensed under orovisi0ns of Chapter 9(common
cine with s«non 1 of oimaon 3 of the Business and Profession.Code, WOODSH GLES
and my Iloenw is n 10) rad Nfe<t.
License Class ]� Lic.Number
Dat. Contractor OTHER ISP IFYI C
OWNER-BVILDER DECLARATION
fin
affirm that I . n «te
exempt from rhe Cptro . License Law for PROPOSED
the f0uowlog reason. (S«. 7031.5, Business and Professions Code: Any city
or county which requires Is permit to Construct, alter, improve,dem.h.h.or
repair env.truclure,prior to its issuance,also requires me applicant for such BUILT-UP ROOF
permit to lila a signed statement that he is licensed pursuant to the provisions
of the Contractor i License Lew (Chapter 9 (commencing with Section 7000)
O
f Division 3 of me Business and Professions Code)or that he is exempt there ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section7031.5 by any eoolicent for s permit Subjects the applicant to a evil penalty
of not mor.mss five hundred doll...($500).1: WOOD SHAKES
❑ I, s of the property, or my employees with wages a$their role
compensation will do the work, and the structure is nor intended or offered WOOD SHINGLES
for sale(Be . 7090, Business and Professions Code: The Contractor's License
Law d0«not apply to an owner of property who builds or improves[hereon,
and who does such work himself of through his own employees,Provided that
..on improvements are not intended o offered for sale. If, however, the OTHER (SPECIFY)
building o improvement Is told within or
year of completion, me owner
builder will have the burden of proving that he did not build Or improve for
purpose ofsala.). PROVIDE I.C.B.O. REPORT NO.
D 1, as owner of the property, am exclusively contracting with licensed
Contractors to construct he project (Sec. 7099, Business and Professions
Code: The Contractor's License Law does not apply toanowner ofproperty PROVIDEMFGR. INSTALLATIONSPECS.
who builds or improves[her.un, and who contracts for such projects with e
contractor(a)
licensed pursuant to the Contractor's License Law.
❑ I em exempt uncle. sec. ,e.aP.c.for this APPLICATION DATE VALUAi ION PERMIT FEE
ODote
rear WORKERS-COMPENSATION DECLARATION I D BUIlding
I hereby affirm that I have a certificate of consent to sell r insure,or a ca
tlflcate of Workers' Compensation Insurance,or a certified copy thereof(Sec. Seismic3800,Lab.C.).
Policy No. Company A� '
B Certified Dopy is hereby Wettish".
JAN 27 19 5oa Total
Certified copy is filed with the city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.❑ CITY I- P R IT' THORIZATION DATE
COMPENSATION I NSURANCE
(This section need not be completed if the permit is for one hundred Col I
bra(Corti or less.) a�
1 cbtiha that m the Performance person
of the work for so which thes permit is L
issued, shall not employ ion Person in any manner so as[o become subject
to the Workers'Compensation Law.of California.
Data NT: ItOt
you ICEshould
ld APPLICANT: tl, herb making o0)Compensation
ions of Exemption,
you an Cold b coma subject m the Workers'Csuch provision.
n..1proviion. a the
Labor Cele. you must forthwith comply with mcM1 provision pr mea permit All f0 hall be inspected prlorto any roofing materiel being
shall be a«mad.rooked.
I certify that I have read this application and state that the above informs In ailed. If a roof IS Installed Without first obtaining an
tion is correct. I agree to comply with all city and county ordimnces and I pec ' I fee for ell materiels for inspection.
.n1. laws relating to building construction, and hereby euthori ze nprbem
tetives o1 this city t0 enter upon the above mentioned Property for inspection
DurpONs.e
(weagr« t0 ears, indemnor and keep harmless the City at Cupertino
against liabilities.judgments,costs and expenses which may in env war«cru.
' against said City in consequence of the granting of this permit. $ NA RE 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