R 4139 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Res 4139
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 STARTEDPERMIT EXPIRES IF WORK IS NOT
WITHIN 180 DAYS OF PERM T ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
�S—dC3DL �� N On RESIDENTIAL ✓ COMMERCIAL OTHER
OWNER'S
�" " � HAZARDOUS ROOF
NAME IYJ Q'• •G�C C✓I�,v W.Gi•G FIRE COVERING
AREA CLASS _
ADDRESS � a 3AmtS�k U/J EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
NAME W Gin'V1P.f� TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
ADDRESS /
CITY&zlh Rn. EXISTING
PHONE_
777- 833( BUILT-UP ROOF \
LICENSE ASPHALT SHINGLES
NUMBER 6
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 of Ilcros«undo provision of Chapter s on.Godo-
eine win Section 7000) of Division 3 0l the Business and Profusion COtle, WOOD SHINGLES
and my Iicena fv0 ca aha albct. �f• +�
License Cass —h�r Lic.Number / L
Oen Ctmr«tnr5� OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am..empt from the Contractor'. License Lew for PROPOSED
the following reason. (Sao. 7031.6, Business and Professions Code: Any city
or county which requires a permit to construct, .Iter, Improve, demolish,or
repair any structure,prior to Its issuance, also requires the appllunt for such BUILT-UP ROOF
Farm
to fit.a.igned.tanmmt et he is licensed pursuant to t.provisl on.
of the Contrector i LLuc, ee Lew Cnapto 9 Icommencinp with S«tion]0001
of Ohlsion 3 of the i n.en Pronssinne Cadet or[seat see b pump[mere ASPHALT SHINGLES
from sea tna bell fes the la tl evmption, Any viobtlon of Section
]031,8 by any .P for p r it mbjacn t.epplicen<to a civil penalty
of not mon mss i n sed, a a d n 1$6001.1: WOOD SHAKES
❑ I,o own a ro r or my employees with wages es their sola
pen.adon, Ise t W d me structure I.not intended or Offered WOOD SHINGLES
for sen (Sec. ]044, B n entl .ofe 1 o Code: The Contractor's License
Law does not apply an caner of property who build.or improve.m.reon•
and who don,uch rk himself or through his own employees,provided that rlt 0�/✓Pt••is
such improvements ere not intended or offered for sale, If, however, the OTHER (SPECIFY) F�.`6e--y[ u -COL
bu lid i no
or improvement is .Old within one Veer of completion, the owner. fl
builder will have the burden Of proving that he did not build or improve for (,
purpose of sale.).
PROVIDE LC.B.O. REPORT N0.
E] 1, as owner of the Property, am ..Clouvery contracting with licensed
contractors to construct the project (Sac. 7044, Business and Professions
Code The Contractoi, Licamn
License Law PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves tbaraun, no who contracts for such projects with e
Convectorl0 licanud pursuant to the Contractor's License Law.
rsa�n em exempt under Sec, ,Bels P.C.for tM1i. ppLICATION DATE VALUATION PERMIT FEE
Owren Ort.
WORKERS'COMPENSATION DECLARATION Building
I no«y affirm that I neve a certilicata of consam to..If-insure.oracar.
3800'.ab Workers'Compensation Ing^;P V e pY to (S.C. FEB 12
1 Seismic
3800, Lob Y
Policy No ompany
p�Certified y s M1enb�furryEp$tl. `/ W
q'C.rtilie c is i0e- itn.(hf�jt�inspection division. lal�y! L TOt91
APPI Kant fY 6 .[ Vr LVrI, 7' ;f
CERTIFICATE OFEXT ONIION NSUR FROM
WORKERS' N.C.
C, ❑ PERMIT AUTHORIZATION DATE
COMPE(This section need not be completed it the permit is for one huntlred dol �J\�
lars($10M Or less.)
I certify met in me performance of the work for which tni. Permit is
'noes. I shall not employ any parson In any manner so as to become subject
to the Workers'Compensation Laws of California. (�ygO
Date Applicant
NOTICE TO APPLICANT: If, attar making this Certificate of Exemption,
You should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith CPMPIV with such provision or this permit All roofs shall beIna Inspected IIOf}08n roofing material bean
shall b.doomed,.yoked. p P Y g g
I ...tify that I hove read this oPPti..i.h and.tete ton the above inform* Installed. If a roof is Installed without first obtaining an
tion is correct I agree to comply with all city and county Ordinances and inspection,I agree
aue s of hisrelating to building the
ova- and noeby eutoHr. reprn« P//r// fel"X sell new materials for inspection.
purpose.,cal this city to enter upon ma abOv*m«tioned property for inspection
purwe)
I of liabilities,abrea sswam indemnify and Moog harmnu me City of CuOartino xa
against id ityI consequence
coats the g.Penna which may in on, way aCCIVe rl--
apalnt Said City In conegganpe of the priming of 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