R-4149 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO � , IUMBERRSX 4149
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(4OB) Z5Z-45O5 EXT. ZZB WITHIN IN DAYSOF PERM T ISSUANCE OR
IN OA V S FROM LAST CALLED INSPECTION.
BUILDING
'/ADDD.REESSS�� BUILDING USE
2. �.J10 RESIDENTIAL COMMERCIAL OTHER
OWNER'S
iHAZARDOUS ROOF
Ii
NAME 0,57TC 0/ 4 r' 7— FIRE_ AREA CLASS COVERING
ADDRESS-22— ,?7 o. /i C. C 6r.(/�� EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S
G D��/ TO BE REMOVED TO BE RETAINED
NAME � / (r TYPEIOF ROOF COVERING
SE
CDD BEZSp /S'.9 s Z -�+ "'EXISTING
PHONE /G�' 7 BUILT-UP ROOF
LICENSE A LES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under Provision..1 Chapter 9 Ichmmem
cine wish Section 7000) of Division 3 of the Business and Prof...ion.Coda, WOOD SHINGLES
apd my ficanse is 1 lull end effect.
Licame CI n Lic.Number
Dau — Contractor /✓ HER (SPECIFY)
OWNER BUILDER DECLARATION
I nar.by affirm met I am exempt from the Contractor. License Lew for PROPOSED
the following,. M.c. 7031.6, Bu.in.0 end Profession.Code: Any city
or county which requires a permit to construct, altar, improve, demoli.h,or
,.pair any f r..tu..prior to its issuance,also requires me applicant for such BUILT-UP ROOF
P. to fila•.toned statementmat lie i.licensetl pursuant to ma provisions
of the Contractors License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Profession Codel or that he is exempt there ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031b by any applicant for a permit subject. the applicant to a civil penalty
of not more that five hundred dollars 4500).): WOOD SHAKES
❑ 1,as owner of the property, or my employees with wages as their Sol*
compensation,will do the work, and the structure is not intended o offered
for We (Sec. ]Osie, Business and Professions Code: The Contractor's License WOOD SHINGLES
Law do•s not apply to an owner of property who builds or improv+thereon,
and who does such work himself or through his own employees,provided!that
such improvements are not intended ocoffered Per sal.. n, however, me HER (SPECIFY)
building a mprovement is fold within one year of completion, the owner
builder will hrv.Ilia burden of proving that he did not build or improve for
ppr 1, aceta.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, s st m• progeny,t ( exclusively cosiness nn with licensed s
cpmranpr. m construct m• protect (sec ]Osie, Business and Professions
ode: TheContractof'sLicense Low does not apply toanowner o+Property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improve.thereon, and who contracts lot Such projects with a
contractor(sl licensed pursuant to the Contractor's License Law.
❑ am exempt under s.<. ,Bea P.c.for this
I.an APPLICATION DATE VALUATION PERMIT FEE
Owner Det. 4
WORKERS-COMPENSATION DECLARATION r 00 Building
1 "of orkers that have i certificate of concent to copy Cher ore[sir.
3800,e of Workers'Compensation Insurance,or s certified copy (hereof(S.C.
!Seismic
]800,Ler.C.I. y e(5
16
Policy No. Company F�T1f//AJ
8 Certified copy Is hereby with
he cit n TotaI
Certified copy i,sled wish m:city impaction dwisio OF LUH-
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N C ❑ T AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section nod not be completed it the permit is for one hundred ddb
IS,.(5100)pr Iffsthat
i /
I certify mat in me .any person of the work for which co permit is J
issued, .hall not employ any parse o in any manner so as to become subject
to the Workeri Compensation Laws of California,n
Data
plicmnt
f.
NOTICE should
APPLICANT: o altar making this Compensation
P of Exemption,
you ehCod recd me Subject i the comply
w h such nro ion ns oifthis Of I11•
Labor cod.,you mus forthwith comply with such proyi.mns or this permit All roofs shall be Inspected prior to any roofing material being
.Hall be deemetl revoked.
I certify that I have read this application and state that the above informs Installed. If a roof Is Installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinances and p
inspection,I8 agree to remove all new materials for inspection.
.tat. Tawe totaling to building construction, end hereby authorize •epresm. p g
tnivo of this city to enter upon the above-mentioned property for inspection
purposes.
(Wel agree to save, indemnify and keep harmless the City of Cupertino
again.[liabilities.judgments,costs and expense.which may in any way accrw
aZnst said City in consequence of the granting 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