R-4202 (2) • PERMIT Rxe 4202
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN TIN DAYS OF PERM T NOT
OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - BUILDING USE
.21144 Wy4.v1V1's PO#s% DaYfdE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
• A_'/ //�
NAME R O/1/Ct� COLTo/) HAZARDOUS ROOF
FIRE COVERING
t, ll AREA CLASS
ADDRES//a/9 411150 112024 tiIO✓ASOPP e7— //!e�✓�1 EXISTING ROOF COVERING
PHONE C/-o lr -Zsi 091D 7,61 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADDRES
CIT 8t ZIP • EXISTING
BUILT-UP ROOF
PHONE
LICENSE
NUMBER
LICENSED CONTRACTORS DECLARATION
av-
I hereby affirm Mat I of licensed under provisions of Chapter Professions
s(commend
int, wins s«tion 70001 of Division of the Business elle Protasaiom code, D SHINGLES
and my license F In full fora end affect.
License Coss on mber
Nu
Cnrtactor OTHER (SPECIFY)
Dsu o
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from me Contractors License Law for PROPOSED
1".following r (Sac. 7031.6, Business and Professions Code: Any city
or county which require. a permit 1.construct,alto, improve, Carl �O p/�
repair any structure, prior to its Issuance. also requires Me applicant for such T-lJ�flOOF lit
permit to Ills a signed statement that he is licensed pursuant to the provisions
of the Contractor's Lien. Law(Chapter 9 ICommeocing with Section 70001
of Division 3of Me Business and Professions Code)or that he is exempt more IN
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a Civil penalty
of not more that live hundred dollars($500).1:
❑ I,as Owner of the property. Or my employees with wages of their sole
Compensation,Will d0 Me work, and me structure is not intended or offered
for sale (Sec. 7044, Business and Prof essionsCoca: Th.Contris"or'f Lice... WOOD SHINGLES
Law does not apply to an owner of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that
such improvamenn are not intended o offered for sale. If, however, the O PECIFY)
build i ng
or improvement is sold within one year of completion, the owner
builder will nava the burden of proving That he did not build or improve for
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Low does not apply to an owner of property PROVIDE fill INSTALLATION SPECS.
who buildi of mprove$theraun,and who contracts for such projects With a
contractor(s)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sac. ,B.i9P.C.for his
APPLICATION DATE VALUATION PERMIT FEE
owner D.[.
WORKERS'COMPENSATION DECLARATION OCTuilding
I hereby affirm [he[ I have i certificate , cement to sellinsure. o can 3100, of Workers' Compensation Insurance,or a certified copy thereof(Sac, y r eery $elSmlC
PolkNo.LabC.). /L�
PoIICV No. Company ) r
B
Certified copy is naraby furnishaa (/�'l rL " Total
Certified Copy b filed with the city inspection division, VI
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N C ❑ PERMIT AUTHORIZATION DATE
COMPENSATION NSURANCE
(This..T,.n head not be completed if the permit is to,One hundred d01. MI
Is's($1001 or Iese.)ly SnM
I carliot in e performance of the work for which this permif if
issued, I Nell not employ any penin in any manner so as to become sublact
t0 the Works a'Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption,
You should bottom. subject to the Workari Compem.lmh provisions of the
Leber Coda, you must forthwith comply with such provisions or this pomp All roofs shall be inspected prlortoany roofing material being
shall be deemed rinvoked.
1c.rtifV the, I have read this application and stets that the above Informs installed. If a roof Is Installed without first obtaining an
tion is coria t. I agree to comply with all ciity and county ordinances and inspe tion,Iagreetoremovea new materialsforinspection.
tete laws lating to building construction, e d hereby authorize epresen-
otives of this city t0 enter upon the above mentioned property for inspection
purpose.. /o.3-9
(Wt l agree s, uva, indemnify and xpe harmless ma City of Cupertino
against liabilities, cones Lie cell and ax Ming which erV in mY way accrue
.gains said City m consequence of ma granting of this Permit. I NATURE 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