R-4432 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R' 4432
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
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/� �j��� - BUILDING USE
7/' �J l/ �� �/f' . RESIDENTIAL �ICOMMERCIAL OTHER
OWNER'S /�a,, '/� //�y� ��• ROOF
NAME _ lyey/G '-""'���YGu� FIREHAZARDOUS . COVERING --.
-,// j' AREA CLASS
ADDRESS. v , w�'��T.e/7�s2 / EXISTING ROOF COVERING
PHONE (7� ��+� �� NUMBER OF EXISTING COVERINGS Z
CONTRACTOR'S
�O�/ TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
CD Y III Z10 ///0g0 �` �'�?'' f �+'O 0 EXISTING
I PHONE_ (Y/O( 9TnI/ BUILT-UP ROOF
LICENSE '7 ASPHALT SHINGLES Z
NUMBER 2s /
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 h00abY affirm 7000 I of Ilnn..d unser provisions of Chapter Prof..(comment
inv with Section 70001 f Division 3 of the Business ane Proisslon.cps., WOOD SHINGLES
.on my licmea i%In f f rad affect. 7z
Lmama Cba� Lic.Number
Date j-z•�_ ccn7r«mr OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby.firm met 1 am exemp7 from the Contractor's License Lew for PROPOSED
me toll owing reason. (Sec. 7001.5. Business and Professions Code: Any city
or county which requires a permit to construct, altar, improve, demolbh,or
ip.,I any structure.prior to its issuance,also requires the applicant for such BUILT-UP ROOF
Pari t to file a signed statement that he Is licensed pursuant to the provisions /
of Cha Contract.'. License Law (Chapter g (commencing wins Sermon)000)
I f Division s of the Business and Professions Code)or that he is exempt mare ASPHALT SHINGLES/
from and the basis for Ina 00lagat exemption. Any violation of S«tion
7031 by any spit ant fora permitubjects the applicant to a civil penalty
of not more met five hundred dollars(115001 .1: WOOD SHAKES 57
❑ 1.as owner of the property, or my employees with wages as their sole
compens.tim•win do me work, and the structure is not intended or offeree WOOD SHINGLES
for..ie(Sec. )044, Business and Professions Code: The Contractor's License
Law does not apply 10 an owner of property who builds Or improves thereon,
and who do.such work himself or through his Own employees,provided the,
beach improvements are not intended oroffered for sale. It however, the OTHER (SPECIFY)
uilding a improvement 1+ sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
pumc.aoe.ale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, f Owner of the property, am exclusively contracting with licensed
contractors w construct In project (Sac. 7044, Business and Profession.
Code: Th a Contractor's ii Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improve% tharsun, dna who contracts for such projects with e
contractor(s)licensed pursuant to the Contractor's License Law.
❑ am exempt under sea ,B.aP.c.for his
APPLICATION DATE VALUATION PERMIT FEE
won
Owner Data
—
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I have a certificate of consent to self-insure,or a car O
tibc.te of Workeri Como emaf on Insurance,or Certified coo, thereof(Sac. $el$mIC
3800,Leb.C,rl (/�/T/OL t�p..n `�f_'
Police Na._{i7/ - _Company` I '_-`
B Certii d copy is hereby to rthe Cit. _ _ FEB 27 (t[C� iTotal
( Certifies copy is filed with the city spec - n divman. R[,l7
APOliunt 04/
CERTIFICATE OF EXEMPTION FR WORKERS' .P,E IT- UTHORIZATION DATE
COMPENSATION I N B UR NCE N.C.
(This section need not be completed If the permit is for one hundred Cob ^ l7
bra(5100)or Iass.l G q
1 certify that in the performance of the work for which this permit is
inueb. I shall not employ any person in any manner to as to become subject
fes the W. i Co ...tion Laws of Cali(p ya� n
Dau��C AT: If. ki Ia/J
NOTI E TO APPLICANT: If. .M1a making this Cartiii.e.s oxamption,
you mould become subject to the Workers'Compensation Compensation pro ns of the
Labor Code,you must forthwith comply with such provisions or this permit All roofs shall be inspected prlorto any roof Bteria being
shall be deamed evoked.
I certify Chat I naw nae tNuppliuron dna sura mat the above info.ma. installed If a roof is installed WI t first Obtaining an
tion is torr«t. spree to comply with all city dna county ordinances dna Inap Onr agraBtO wmaterialsforinspection
nate laws relating to building construction, and hereby authority represent
btiva+of this city to enter upon the above mentioned property for insp«tion
ouroosss.
IWaI pree to sees, indemnify and bap harmless 7n• City of Cupertino
s
against liabilities,judgments,costs and expenses which may in any way accrue
against said City in consequence of the granting of this Permit SIGNA RE OF PPLICANT 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