R-4056 (2) PERMIT R- 4056
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)) 252-252-45055EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN80 DA S F OM LASAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
RESIDENTIAL / COMMERCIAL OTHER
OWNER'S
HAZARDOUSOOF
NAME Z DS S^\ �I�n,� FIRE COVERING
AREA CLASS
ADDRESS Q T L�Tx ^D����<Y bQ��rr LIQ EXISTING ROOF COVERING
PHONE :;L—
C
NUMBER OF EXISTING COVERINGS
CONTRA TOR'S
TO BE REMOVED� TO BE RETAINED
NAMEIM TYPE OF ROOF COVERING
DD
CIT aiih 103Co� �Qc9 r-��E{v�-�1 (� .EXISTING
PHONE IA ' 2915 -A4 ` BUILT-UP ROOF
LICENSEccs! 3s� ASPHALT SHINGLES
NUMBER JJ
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I nappy Section
that I of Division
under provisions of Chapters ons(commen.Cod
mg with secRpn 70001 or Diyl.ion 3 or m.Business and Professions cod., WOOD SHINGLES
and my Ilcenu i in lu4 a ane affect.
Llum Class \ Lic.Number
Data a convwaor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I homy affirm met I am exempt bpm the Contractor's License Law for PROPOSED
the following reason. (Sec. 7031.8, Business and Professions Code: Any city
or county which requires a permit to c nstruct.alter. Improve, demolish,or
repair any structure, prior to its issuance,also requires the applicant forsuch BUILT-UP ROOF
permit to RIs a signed statement that he is licensed pursuant to the provisions .,n
Of the Contractor's ft License Law(Chapter 9 (commencing with Section 7000)
firm
Division 3 of me Business dna alleged
exemption.)or that he is exempt more ASPHALT SHINGLES
from end the basis for me apermi exemption. Any violation of Section
of hot o any applicant fora pomp subjects me applicant to a civil penalty
of not more twat rive the redpro erty, r my em WOOD SHAKES
❑ I,as owner of ,tie property, or my employees with wages as their sola
compensation,will do the work, and the structure is not intended or offered
for sale (Sec. 7044, Business and Professions Coda: The Contractors License WOOD SHINGLES
Lew doe not apply to an owner of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that
such improvements are not intended or offered for Mile. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
builder will neve the burden of proving that he did not build or Improve for '
Purposeofaal.1. PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the property, em exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Profession%
ode: The Contractor'sLicenseLowdoesnotapplytoanownerofproperty pROVIDEMFGR. INSTALLATIONSPECS.
who builds or improves theraun, and who contracts for Such projects with a
contrec for(S)licensed pursuant to the Contractor's License Law.
ronin I em exempt under Sac. ,B.&P.C.for this
Own. Date PPLIdAtION-DATE VALUATION PERM EE
WORKERS'COMPENSATION DECLARATION JUN y 1 �1f���JvL'11/� Building
1 h.r.by affirm that I have a certificate of con. t,o salt ln.ur 1995 N/'-�
tifica,a of Workers Compensation Insuran or c tit ac pymeraof(Sac, Seismic
3600,Lab. ,n tfl__}_ () ^/f
PBOB Awe ?.)�l Company��LLR\U C 111�1e� lx G l
Certified Copy is hereby furnished. UrEk rlNp Total `
Certified copy is filed with the city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.C1PERMIT AUTHORIZATION DATE
COMPENSATION I INSURANCE
(This Action nee not be completed if the permit is for one hunmed doL
tars(S1 W)or leas.)
I certify that in me performance of the work for which [his permit is
issued, I Shall not employ any person in any manner to as to become subject
to the Work.,.Compensation Laws o1 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 cod.,yougat forthwith comply with .q<n provisions or,ni.perms, All roofs shall be in ted prlortoany roofing material being
se.0 b.%..mea revoked.
I certify that 1 have read this eppllution and state he, he above inform. Installed If of ' I ed without first obtaining an
Ren is Correct. 1 .gra 10 Comply with all city and county ordinances and Inspection t Va all new materials Porins action
state law. ral.iing to building conftructi on, and hereby etimcnixe repref.m P P
tativas of this city,o enter upon the above mentioned property for inspection
purposes. f17
(We)l agree to siva, indemnify and keep harmless a City o1 ay accrue
against said
Cbas, consequence
tet cotta dna expenses which they In any way accrue
ewimm oia ctry in<on.equenge of me granting of this permit. SIG AT E O 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