R-4234 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- '4234
REROOF PERMIT 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 ,a G �Y BUILDING USE
�a CC- 1 �`� �`C - RESIDENTIAL COMMERCIAL OTHER
OWNER'S
/aS HAZARDOUS ROOF
NAME ( - ( FIRE Use COVERING
p� � U� AREA CLASS
ADDRESS « L �e /i ic he, EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME I TYPE OF ROOF COVERING
CIDTY&Zla ` EXISTING
PHONE I r7— 2 BUILT-UP ROOF
LICENSE / ASPHALT SHINGLES
NUMBER (O OD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provision.of Chapter 9(common
cin. with Section 7000) of Division 3 of the Business end Prof..0 oda, WOOD SHINGLES
and my licnis in i Ill d fact.
Datalt
CI:."` Lice Number U
Data �z l conn«[orlbp,FAA � OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm that I . mp, nom the Contractor's License Law for PROPOSED
the following reason. IS«. 7031.5, Business and Profen ions Code: Any city
Or county which requirM is Permit t0 Construct, aIter, improve,demolith,Or
repair any structure.Prior to its issuance,also require the applicant for such BUILT-U
Permit to file a signed statement that he is licensed Pursuant to the provi.lons
of the Contractors License Law (Chapter 9 (commencing with Section 7000)
from
Division 3 of the Business the end Proalleged
exem tion. or that be i.exempt here
dire ASPHALT SHINGLES
Iron and Me beis for ess alleged asions Cod Any violation OI Section
7031.5 by any applicant for a permit ubacts the applicant to a civil penalty
of not more that five hundred dollars($500).1:
❑ I,a ge
err of me Property,Or my employee.With was n their.ole
compensation.v/i0 do me work, and the+tructu.0 is not intended or on.rad WOOD SHINGLES
_
for asle (Sec. 7044, Business and Professions Code: Th.Contractor.License
Law doe not apply to an owner of property who build,or improves mere on, -t
and who dam such work himself or through his own employees,provided that
such Improvements are not immnded or
offered for fall. If, however, the OTHER (SPECIFY)
building or improvement it sold Within one year of completion, the owner.
builder will have the burden of proving that he did not build or Improve for
pulpa..of.ale.). PROVIDE I.C.B.O: REPORT NO.
❑ 1, a, owner of the propert Y. am exclusively contracting with licensed
o tractors to construct the Project (Sec. 7044, Business and Prof e+.ions
Code: Th e Contractor's License Lew does not apply to an owner Of Property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improve meson, all who contracts for such projects with e
contnctor(s)licensed ponuent m the Contractor's License Law.
,...an
l am exempt ether sec ,B.aP.c.for this APPLICATION DATE VALUATION PERMIT FEE
Ow Dau
Own., WORKERS'COMPENSATION DECLARATION PQ / Building ldz�.
1 hereby affirm that 1 have a certificate OI consent 10 sal Linawe, err
3 00 a,war Compensation lnsy..nce��ic.�r[IraTd cos�y�.vn.�r.aj is.c. Seismic
3800,Lab /(j 1/`J�C/� 1_`AILC71'W u
Policy No. Company I�v M� q
�.I fi.of aoP In br famished,t r 1e I p R4 O Total
o Corti tied filed w n mea Pec,ian civilian. e11 f. gO lO
Applicant G „MlLvO 1y V
CERTIFICATE OF EXEMPTION FROM ORKERS' N D ❑ " U�Ur -ERMIT AUTHORIZATION DATE
COMPENSATION INSURAN E IY(f
(This saction need not be completed it the Palmi[ if for one hundred cob
fan 151001 or Ism.)
' I Certify that in the performance OI tea work 10r which this permit it
d, I mall Ot amp l Oy any person In any antral at to become subject
to me VUjprkA nrpenution Law.of ilor is
Oeste ("'d-'� Applicant
you ICEShould
ld APPLICANT:subl 0 afar makinrkers' this Camila•a of ,on. Psion,
you mould bacons subiact t0 h c mply with
h such p,civi proviathis a ma
Labor Code,You nun forthwith comply Wim such orovi.iom or this permit All roofsshall be inspected prior to any roofing material being
shall be deemed revoketl.
l cooly mat l nave sed[his applknion acne std.the ma above infarmA installed If a roof Is Installed without first obtaining an
at&n i,laws rela I tors. to ng construction,
on with .II aid and county oris. rel and ins ion,I agr e to r�ve all new materials for inspection
tbb laws relating t0 building n the above
and hereby cert Ofor nPrnen
purpose of this city to chair upon mo ebovpmentioned property for inspection
(We),l agree s, +ave, indemnify costs
and bop harmless the City of Cupertino
e1,111 liabilities,judgments,cosh and expenses sonhis sup in any weY accrw
ewiet trio cid in<onwauenu of the granting a,this mania. 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