R 4143 (2) OMBERResRMIT
APPLICATION FOR CITY OF CUPERTINO 4143
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
' ° 20Q'36 aAos:� C.TRESIDENTIAL COMMERCIAL OTHER
OWNER'S
NAME�� Y � '�? J HAZARDOUS j y1 ROOF
FIRE �Q/ COVERING
' w AREA CLASS
ADDRESS 2,0634 ii RA LL4, r; EXISTING ROOF COVERING
PHONE r NUMBER OF EXISTING COVERINGS
CONTRACTO 'S
NAME_ M JN rE�/��/cad TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
ADDRESS
CITY&ZIP W Adul.Uk IM EXISTING
PHONE Y4 ' IL 111711, AQ BUILT-UP ROOF
LICENSEAS IN
NUMBER
OOD SHAKES
LICENSED CONTRACTORS DECLARATION
I herewith S affirm that of licensedunderof t provisions of d Pear s 4coon.Code,
cine with Section 70001 of Division 3 of Me Butlnase end Professions Code, OD SHINGLES
and my license Is full and effatl.
License lea
Contractor
OTHER
OTHER (SPECT 1
pate ea Contractor
015M
ER BUILDER DECLARATI VA
I noebyy affirm the, I am ...M,t from the Contractor'. License Lew for PROPOSED
the following reason. (Sao. 7031.6, Business and Profession.Code: Any city
Or county which requires a Permit to conatrucL alto,improve, demolish,or
,.P.lr any structure,prior to its issuance, also requires the applicant for ouch BUILT-UP ROOF
P6= 10 file a signed statement that he is licensed pursuant to the provisions
of Me Contractor'.of the License Lew rofessioChapter , (commencing with exempt t7000)
he,.
of Division J of the Business and Profmioes Code)or that he I.exempt mere
from and the basis for the alleged exemption, Any violation of Section ASPHA LES
7031.6 by any applicant for a permit subjects the applicant to a civil penalty
of not more that five hundred d.IAS($6om.): OOD SHAKE
❑ I,as owner of the property, or my employees with wages as their sole
com Formation, will do the work, and the structure is not intended or offered
for sea (Sec. 7044, Business and Professions Coda: The Contractors License SH INGLES
Law do" not apply to an owner of property who builds or improve.thereon,
and who does such work himself or through his Own employees,Provided that
such Improvements are not intended or offered for ala. If, however, the 0 (SPECIFY)
building or improvement I. sold within one year of completion, the owner
builder will have the 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 the PIOPertV. am exclusively contracting with licensed
convactpre to construct the project (Sec. 7044, Business and Professions
Code: TheComractor'sLicense Law does not apply toanowner.1Property PflOVIDEMFGR. INSTALLATIONSPECS.
who builtl. 'mprovee tbersun,and who contracts for such projects with e
contractors)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. .B.&P.C.for this
'sono"
Owner APPLICATION DATE VALUATION PERMIT FEE
Date
WORKERS'COMPENSATION DECLARATION M n
BUIId In�
I raby affirm mat I have a cortifical.Of consent to self.inture,or a car
3600MAIN kari n Insurance,Or a certliied copy th sof IS.C. r Seismic
POIIcY No. I b .�+yI:"V�'d-ATF_x��,c�J MRi fl 199
I] C.11, A COPY n;hoeby furnimad. 2 Total
7 C.rtifie op bd lh to i int lion division. ��� I 7 O
Applicant
` R COMPENSATION INSURANCE ORKE RS' N.C. ❑ TAUTHORIZATION DATE
(This section need not be completed if the permit in for one hundred dol. /I
lam($100)or IHe.) (\V
I certify that in Ma performance of the work for which this permit it
Iseult
I shall not employ any person In any manner to as to become subject
to the Workers'Compensation Laws of California.
One Apolio.nt
NOTICE TO APPLICANT: If, afar making this Certificate of Exemption,
You should become sublact t0 the Workers'Compensation provisions Of the
Labor Code, you must forthwith comply with such provisions or this Permit All roofs be
mall be tle.me l revoked. Inspected prior to any roofing material being
I certify that I have read this application and tate that the above inform. Installed. If a roof Is Installed without first obtaining an
tion i,m rely I spree t0 comply with ell city and county ordinances re r area Inspection,Iagreetoremoveallnewmated Isforinspection.
state ,of his city to building the above and hereby authorize rs prsem
fetives OI this city to mtat upon the abovementioned property for inspection
Purpose..
IWaI spree to cave, indemnify and kap harmless. the City of Cupertino
opsins.IlabilltiH,ludgmenb,cosy and expanses which may in my wry Accrue
against Sold City in conseouence of me granting of this permit. SIGNYUVODFAPPLICANT 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