R-4142 (2) PERMIT
- 4142APPLICATION •FOR • �c�P PERTI NUMBERR
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT
180 DAYS OF PERMIT NOT
OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
1-1 DDDf
RESIDENTIAL COMMERCIAL OTHER
OWNER'S I
HAZARDOUS ROOF
NAME 9 nn
_
FIRE / COVERING
'/��' ff,� n�, AREA CLASS
ADDRESS /-(� W1j+'� rg. CT EXISTING ROOF COVERING
PHONE d'J��'✓ 1 NUMBER OF EXISTING COVERINGS
CONTRACTpR'S /�
IL_. � p A.. J/ � IIL&! TO BE REMOVED TO BE RETAINED
NAME r 1WVp�Ll�/'GV,.,•c�Fti V 9 TYPE OF ROOF COVERING
ADD 1 Li/IJ EXISTING
PHONE BUILT-UP ROOF
LICENSE n ASPH GLES
NUMBER /-7 12--2-7
WOOD SHAKES
LI CENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter a lcommem
cin. with Section )000) of Division 3 01 the Businessand Prof...i s code, WOOD GLE.S. i B
and mV Ilunse i.in f / era.NKL �, I Z 11�
Licm. CI u Lic.Number_ _
0..e convK\or yy I• —1117 OTHER (SPECIFY)
OWNERBUILDERDECLARATION IIA � ���
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED Y� 5
the following rumn. (SK. 7031.6, Business and Professions Coda: Any city
On county which requires a Permit to construct, alter, improve, demolish,or I f
repair any structure.Prior to its issuance, oleo.arlubes the applicmtfar suchBulLT-uP Roo -/No
Permit to file a signed statement that he o licensed pursuant to the provision d UUPEkI
of the Contractors License Law (Chapter 9 (commencing with Section 7000) A r7
' 01 Division 3 o1 the Business and Prof...on.Codal or that he is exempt more ASPHALT SHINGLES r
from and the basis lar fere alleged ...mPli.n. Any violation of Section
7031.5 by any all.., fora Permitubjects the applicant to a civil penalty
of not more that five hundred dollars($500 ).): WOOD SHAKES
❑ 1,as owner of the property, or my employees with wages as Hies,sola
compensation,will do the work, and the structure is not intended or offered WOOD SHINGLES
for sole v
(Sec. 7044, Business end Professions Code: The Contractor's License
Lew does not apply io on owner of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that
such improvemams are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
builder will neva me burden of proving that he did not build or Improve for
purpose of sale.(. PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of ma property, a xclusively contrKling with licensed
antras ton to construct the project (Sec. 7044, Business and Professions
Code: Tha Contractors License Law does no,apply to an owns,of property PROVIDE I'll INSTALLATION SPECS.
whobuilds of improve{thereon.and who contracts for such projects with a
cant ractor(s)licensed pursuant to the Convector's License Law.
❑ 1 em axemp\ under sae. ,B.aP.c.for this
reason APPLICATION DATE VALUATION PERMIT FEE
Owns. Data
WORKERS'COMPENSATION DECLARATION Building
I Mnby affirm that 1 nava a certificates of consent sem to[o self-insure,or a can ( w
\i fi<ato OI Worker Compe�gotinsurence,or a certified copy thereof(Sec. I. x I lA �/f� Seismic
3800,Lab. t '1` f(7s 44u_—rrj4A {� 1 v—
Policy No. .Company
BCo If i a copy Is hereby furnished. Total
brtiliea copy b files with ma city mlpec Von division.
Applicant
CERTIFICCOMPENSATIOATE OF
PN INSURANCE WORKERS' .TION FROM N C PERMIT AUTHORIZATION DATE
(This section need not be completed if the permit is for one hundred doL ��
I...($100)or Iess.l
I certify toot in the performance mfr ss. of the work for as which this permit is
trued, I snail n01 employ any pawn in any manner\O as\O became subject
m me Workers'Compensation Lam of California.n
Data Applicant
NOTICE TO APPLICANT: 11, offer making this Certificateof Exemption,
you should become subject to the Workers Compensation provisions of the
L.bar Cad., you must forthwith Comply with such provisions or this permit All roofsshall beinspected prior to any roofing material being
.hen be assured revoked.
I twill, met l h......d this.pplicatl.n and.ut.mel the above inform.. installed a roof is installed without first obtaining an
Ilan
is correct. l agree to comply with all city and county ordinances and Insp ti agree to remove all n w materials for inspection.
state laws relating to building construction, and hereby authorize rep....n'
tetives of this city to enter upon the above mentioned property for inspection I r
purposes.
IWe) agree to save, indemnify and keep harming the City of Cupertino l
against liabilities,judgments,Costs and expenses which may In any way accrue
against said City in consequence of the grsming of this 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