R-3974 (2)40
0
OFFICE COPY
PERMIT
R- 3974
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT '228 WITHIN EXPIRES80 DAS OOF F PERMIT ISSUASTARTED
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
- BUILDING USE
A• l/1 �Y� IF
RESIDENTIAL COMMERCIAL OTHER
OWN ER'S a
C ��p
HAZARDOUS ROOF
NAME �Sa' SIV
FIRE COVERING
AREA CLASS
cpr2 I� \ �11p ��
�
EXISTING COV
ADDRESS. (IIjL)M7y�L 'COY%YNLl%�t�]
ROOF
NUMBER OF EXISTING COVERINGS
� � -7
PHONE " V • ✓ /
TO BE REMOVED TO BE RETAINED
CONTRACTQp'S , / ^C /1
/�,
TYPE OF ROOF COVERING
�/Jl/lf 1(J IK"v�]V�I1
NAME
cD°vaii6
EXISTING
PHONE
BUILT-UP ROOF
LICENSE8�C'
ASPHALTSHINGLE�
NUMBER O
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that 1 em licensed under previsions of Chapter 9 (comm.h
70
WOOD SHIN S
tiny wim s colon of n of the ...iha a asi .
and my licmea is In i I erg qivi
fact.-;
1
Licari . C a Lic. Number
Data Contractor
OTH PECIFY)
�
R -BUILDER DECLARA
I hereby affirm that I am exempt from the Contractor's LiceF • •
P QPQ$ED '
the following reason. (S«. 7031.5, Business and Professions Code: Any city
or county which require. a Permit to construct, alter, Improve, demolish.or
O
.par env mucmra, prior to in issuance, also require. the applicant for .um
UI LT -UP ROO '
P.M.,
-mto ills a signed statement that ole Is licensed pursuant to the provisions
of the Contractor', License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Profession. Code) or that he is exempt more.
`—
AS ALT e
fromand the basis for the alleged a .motion. Any violation of Section7WI.5
by env applicant for a permit ubiacts the applicant to a civil penalty
of not more that five hundred dollars ($500).1:
WQQ HAKE
❑ I, as owner of me property, or my employees with wages as their sola
compensation, will do the work, and the structure is not intended or offered
for sale (Sac. 7044, Bushes. and Professions Code: The Contractor'. License
WOOD SH LES
Law aeras not apply to an owner of property who builds or improves oras thereon,
and who tlon such work himself or through his own employee; Provided that
r o ,.-VI �1i V�/v�./�l/'/•F/
such improvements are not intended or offered far sale. If, however, the
building or improvement is sold within one year of completion, the owner.
OTHER (SP
builder will have the burden of proving that he aid not build or improve for
_
°"'El
PROVIDE I. EP RT NO.
❑ 1,
"a'olwne the property, with licensed
. .0.
contactors st t ( ec.7exclusively4.contracting
construct the [ (Sec. end Professions
Bto
an o
case: Tbs Contractor's se La t app of property
apply fee
un and doeswho
PROVIDE MFGR. INSTALLATION SPECS.
cot
who buildsimproves [names, entl wno each Pr
esthen lar a
project. witM1 e
eo ac or( ) licensed actorecLL
a La
an[ to tM1e Convenor's License Lew.
Ci 1 am trip,pea er
❑ am axemat "oder se=. ,6.6P.C. for this
reason
APPLICATION DATE
VALUATION
PERMIT FEE
r
ow her
ow eras
WORKERS' COMPENSATION DECLARATION
Building
1 herby affirm mat 1 have a certificate of consent to self -insure, o
P1 Al r'
oficon of Workers Compensation Insurance, or a certified copy [hereof fSec.
Y- W
del
Seismic
3800, Lab. C.I.
J
Policy No. Company
copy is hereby furnished,
/1 /.r�
I'
Total
eC.,fei.d
w thdcid.
Certified copy it filed with the city impaction division.
WAR 2 19
5 L/ I
Applicant
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. ❑
COMPENSATION INSURANCE D
-
(This section need not be completed if the permit is for one hundred dol.
len ($100) or Iess.)
I certify that in the performance of the work for which mix permit is
Issued, assail not employ any Lenon in my manner to es to become subject
n
t° the Workers' Compensation Lews of California.
Dae Applicant
NOTICE APPLICANT: If,o after this of Exam oboes,
should Workers'
you .Houle b«oma alibi«t to the Workari Compenation provisions of the
Compensation
Labor code, you must forthwith comply with such provisions or this permit
All roofsshall be inspected prlortoany roofing material being
shall be deemed ak.d.
Icertify that I have reed this application and state that the above informs
Installed. If a roof is instalIV without first obtaining an
non is correct. I agree to comply with all city and county ordinances and
ins eCtlOn, gree t0 remove I new materials for inspection.
state ranting to building n.,
and hereby autnorix6 rep;.
ep
of
popes a] this city m enter upon tna aDOvementipnad ono Lerry for imp«tion
enter the above .
purpose.
al l
IW 1 aorea say., indemnify end keep the City of Cupertino
against liabilities. judgments. costs and expenses which in env weer accrue
s. es which
SIGNATURE OF APPLICAl DATE
lie,
against said City in =an..qu.n=e of the m•neny of this permit.
er
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