R-3991 (2) PERMIT R_ 3991
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT - INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 NOT STARTED
4ETHRMIT I N 1180 DAXPIREYSOFPRIF MIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
100 BUILDING ADDRESS �+ /'�` BUILDING USE
L11Cv _ 0 �G ' RESIDENTIAL COMMERCIAL OTHER
OWNER'S
NAME IW✓ �li-e`�` HAZARDOUS ` „ ROOF
FIRE � o COVERING
AREA CLASS
ADDRESS I7Z<�- _124,Il« EXISTING ROOF COVERING
PHONE -if08 — ?_ O`P Z. C NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ' // v�
NAME49�� ,C7.�O,V V- .ter✓ 0���(/ TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
ADD&isf7 77fe� /BALL'' /S onl S_t EXISTIN
PHONE 6/J r— 777 —/2 Xy BUILT-UP ROOF
LICENSE LT SHINGLES
NUMBER Z Z WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provision.of Chapter 9 Icommem'
ting with Section 70001 of Chimion 3 m the Business and Protest,
om Coda, WOOD SHINGLES
and my lienee i.in 1 II fort sod affect. n 7
License Cleat — Ln.Number C—
oate
Contractor
OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm the, 1 am exempt from the Contractor's License Law for PROPOSED
Text,
the following ren on. ISec. 7031.6, Business and Profession.Coca: Any.
ar county which ,ese ire. . permit t0 construct, alter, improve,demolish,Or
repair any structure,prior w its issuance,also requires m.applicant for such BUILT-UP ROOF
Psto Nle a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Coda)or that he Is exempt there. ASPHALT SHINGLES
from ata the basis for me alleged mi exemption. Any applicant
Loon of Section
from and
any bapuunt the
a permit empti n. Any trio ro a club penalty
of not more that ilve hund,.d dollars($600).): WOOD SHAKES
❑ I,e.owner of the property, Or my employees with wage.es[heir sola
compensation,will do the work, and the structure is not intended or offered
for ante(Sat. 7044, Business and Professions Code: The Contractors Litanies WOOD SHINGLES
Law don not apply to an owner of property is o builds to improves Provided
that
and who don such work himself or through his own employee, oves thereon.
e tont
such Improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building o improvement is sold within one year of completion. In.a
builder will ave the burden o1 proving that he did not build or improve for
purpose oaf.own PROVIDE I.C.B.O. REPORT NO.
❑ 1, owner st the property,a c. 70 . contracting with licensed
con Vectors ,o construct the se Law (Sac.not
Business and Prateolom
Code: The of improves thef un. and doewho cot ,acts foauch pr ofOcts property
a PROVIDE fill INSTALLATION SPECS.
who bunds or improves scant to and who actorecn for a La projects with e
contractor(s)am ..mcTd pursuant m the Contractor's License law.
❑ 1 .m .x.mpt under sec. ,e.a P.C.far this APPI3kCATPN DATE VALUATION PERMIEFFE
Own.,
Ow Data
. her WORKERS'COMPENSATION DECLARATION {� R 13 Buildin �"
1 hereby affirm that 1 nava a certificate of consent 1...If or a car
uficata o1 Work.,.Co 3GY���'n'or a caauietl copy thereof ISec. 1995 wee Seismic
3800, Lob.C.) 4'L/L/�O LIl�t:.ZsY d/t�YUQL
Policy Car Company CITY _
8
Certified copy is hereby with
t furnished, / I ( /- I I I tH(i
Certified copy is tiled with the city inspection division. vvr ryU Total
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
0 - PERMIT AUTHORIZATION DATE
COMPENS INSURANCE
(Thi.section need no,be completed it the permit is for The M1u ntlred tlol�
Ips($100)Or Intl
1 certify that in me pony person of the work for suffices this Permit it
toted, I .hell not employ any person in any manner so as to become subject
D the
Workers'Compensation Laws of California.
Data n[
NOTICE TO APPLICANT:NT: 110 e W making this Cerner provisions of Eof on,
you sat Cold become st fort i the Wply wi Compensation nsrhso1 the
Labor CCde, you must forthwith comply with such provision.or this permit
.hell be deemed rwokotl. All roofsshall be Inspected priortoany roofing material being
1 certify that I have rod this application and.tate that the above inform. Installed If a roof IS installed without first obtaining an
:ion is correct. I agree to comply with .II city and county ordinances and inspection,I agree to remove all new materials for inspection.
cab laws relating to building construction, end hereby thorize opre.em
rooves of this city to ants,upon the above-mentioned property for to
DurDO..I. �¢ 1
Vi l agree to save, indemnify and keep harming the City of Cupertino L�� �TL7�C�G�
against liabilities,judgments,coos and expenses which may In any way accrue
.,.,net
said City in consequence of the granting m 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