R-4188 (2) PERMIT R- 418 8
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERMIT ' NSPECTIONDwsioN PERMIT E PEMIT EXPIRES OF ORKI N
OT
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT SUAT CETOR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
qafiQSP� O`�O ` z RESIDENTIAL COMMERCIAL--/�L OTHER
OWNER'S
NAME
^ "" �'`( FIREARDOUS ROOF
COVERING
CLASS
�1 / AREA EXISTING ROOF COVERING
ADDRESS, 12,-7-72 S'1A-2.` S v�L P-0t)00
PHONE / �[ 9�7D NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /�
JAI
Roo F, . L TO BE REMOVED TO BE RETAINED
NAME J t.7 I\ N- 7 TYPE OF ROOF COVERING
ADDRESS f>0 goy( 9�3 C6-M
n EXISTING
PHONE �! / BUILT-UP ROOF
LICENSE '1 ASPHALT SHINGLES
NUMBER / WOOD SHAKES
LI CENSED CONTRACTORS DECLARATION
I hereby off
irm that I am licensed under provisions of Chapter 9(common
cmg with Section 7000) of Division 3 of me Businayla Pro.�,�grla Fyde, WOOD SHINGLES
no my Ilpnse is,its fu7Lio�sed aflecL cam( /
License Cliff C� �.l _ Lic Number
Date 70 s— Contractor �+ ti OTHER (SPECIFY)
OWNER-BUILDER DECLARA ION
I hereby affirm that 1 am exempt from the Contractor's License Law for PROPOSED
the following reason. (S«. 7031.6, Business and Professions Code: Any city
01 county which require$ a permit t0 Construct. sitar, improve, dem Olish,or /�L\
repair any atmcture,prior to its issuance also requires the applicant for such BUILT-LIP ROOF
Permit t0 nIs a signed statement that ate is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
oI Division 3 of the Business and Professions Coda)or that he is exempt mere ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation Oi Section
7031.5 by any applicant for a Permit subjects the applicant to a civil penalty
Of not mice that five nu ndred dollars(9500).): WOOD SHAKES
❑ I, as owner of the property, or my employees with wage$es their$Ole
compensation,will do the work, em me structure is not intended or offered WOOD SHINGLES
for sale(Sec. 7044, Business and Professions Code: The Contractor's License
Lew does not apply to an owner Of property who builds or improves[hereon,
and who does such work himself or through his Own employees,Provided that
such improvements are not intended or offered for sale. u, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or improvefor
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, a owner of the property, em exclusively contracting with licensed
contrac ton to construct rhe project (Sec. 7044, Business and Professions
od.: rneconvac[oraucenseLowdoes not apply toanowner ofProperty PROVIDE III INSTALLATION SPECS.
who builds or improves meoun,and who contracts for such projects with a
contractor(s)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under S.C. ,B.&P.C.for this
reason APPLICATION DATE VALUATION PERMIT FEE
Owner Do,.—
WORKERS:
auWORKERS'COMPENSATION DECLARATION-inyLia Building
1 to at affirm that have i n Insurance
of r a cess, ie self
copy ache, �"{ 0 J
of00, Of Workers'Compensation Imm��nc/e}or-,--c�.er�[ilied�c`oPY meregi(Sec. O� ,L /1 �L..J Sal$mIC r
3800,Lab .).T.l !W �( /'y% C C UN E/�J\ / 1/`v
Policy Np��,�yp Company 3l/(�
I] C.rtified copy b hereby fumi.h.d. _ / ` 1 Total
C.hfiais copy is+ilea with the city inspection division,
Applicant V
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
C 0 VVrP-ERMITAUTHORIZATION DATE
COMPENSATION INSURANCE '1
(This($ 0 r,lei head not be completed it the permit is for one hundred d06 I yLVy
los 1 cerci or less.)
I certify inet in the performance OI the work for as which .. permit it
toted. I shall not employ any Lenon in any manner so as[o became subject
to the Workeri Compensation Applic Lawt of California.
Data NT: if,
NOTICE should
APPLICANT: o afar making this Danif n p of Eons of
the
you
thould b«oma ab)«t to [M1a Workers'Compensation provisions o1 Ina
Labor Code, you must forthwith comply with such provisions or this permit All roofs shall be inspected prior to any roofing materialbeing
an all
be doomed revoked.
I certify that I have road this application and state that the above informs installed If a roof Is Installed without first obtaining an
don is Correct. 1 agree to comply with all city and county ordinances and ins p ction,I agree r ve all new materials for inspection.
state laws relating to building construction, and hereby authorize repress. /�{nJp
n[ives of this City to enter upon[M above mentioned property for imp«tion Q��
purpose. rlY/ 'W�" r • �VN/rN�'/rte �V%L_ / J
(We) agree to save, indemnify and keep harmless the City of Cupertino
.,.ins liabilities, judgments.costs and expenses which may In any way accrue
.,int:tam City in consequence of the granting of this Permit, SIGNATURE OF APPLICANT DATE .
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:-
INSP.
N-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