R-3978 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 3978
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
`may (408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
P% 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /��`) I V�1 �/A 1 / p BUILDING USE
I 0 � V 1 J�� RESIDENTIAL COMMERCIAL OTHER
OWNER'
/y' I RO
NAME
HAZARDOOF
+"X FIRE COVERING
\'\ AREA US CLASS
EXISTING ROOF COVERING
ADDRESS �/-�/
G /��( `
PHONE ` `� CJ J 2— - 9 ) 7 NUMBER OF EXISTING COVERINGS
CONT CTOR'S
TO BE REMOVED TO BE RETAINED
NAM RYY_110, ( TYPE OF ROOF COVERING
DDaSS� `lSO 1 46 a� V
R ( _ EXISTING
PHONE S – `� �7BUILT-UP ROOF
LICENSE Q�'-]i�� ASPHALT SHIN S
NUMBER F� "�1 �
WOOD SH S
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provision,of Chapter 9(co
cin. with +actio 7 01 Q olvNion 3 of me Busina�en Proln,iom Coca, WOOD HINGLES
and my Ilcmes Jim,
+O ll�G.l
q entl a1/em. '-T License �� Li..Number OTHER PECIFY)
Data Connx�r
W -B;IILDER DECL n
Hilihereby ffirm t at I' m pt ooh me contractor+ Licenw L for PROPOSED
tis+ollOwing reason. (Sac, 7031.5, Business and Professions Code: Any city
or county which requires a permit to construct, alter,improve, dem Olisb,Or
repair any structure, prior to its issuance- also requires the applicant for such BUILT-UP ROO
Permit to file t signed Li sbbmaw that ata h (..m Pursuant to tate tion Provisions
of
he Co file a si, Litems law hathe(Chapter 9 (comm encin. with Section 7000)
Of Division 3 of the Business and Plot eni...Code)or he,he is exempt mere A$pHA LT SHING
from end the b.sis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a Permit subjects me applicant to a civil penalty
of not more that live hundred dollars 3500).): WOOD SHlL$M — 6 199
0 I,a er of In.officially. Or my emplOyan with wil".as their sole
compensation.will do the work, and the structure is not intended or offered
r sale (Seo. 7044, Business and Professions Code: The Contractor's License WOOD SdI [JGI&ES
Law does not apply to an owner m property who builds of improves hereon. WFCHI INU
and who does such work himself or through his own employees,provided that
ouch improvements are not intended o Offered for sale. If, however, the OTHER (SPECIFY)
building o improvement is sold within tier one year of completion, me owner
builder will have the burden of proving that he did not build Or improvefor
purposeof sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the property. a exclusively contracting with licensed
contrac tors to construct the project (Sec. 7044, Business and Professions
ode TheContractoisLicense Law does not apply toanowner o+property pROVIDEMFGR. INSTALLATIONSPECS.
who ballot O improves hereon, and who contracts for such projects with e
contractor IN licensed pursuant to the Contractor's License Law.
p em exempt undo. sec. ,e.aP.c,for this APPLICATION DATE VALUATION PERMIT FEE
Owner ON 1
WORKERS'COMPENSATION DECLARATION _ BUIId Iraq
I te0, affirm that I neve a certificate of consent to salbinsure, e car , � I -I-lll 111 /�
3 00', of Workers' 1n,urenc If' d epv me.a rf ISec. I r n( C $BISRIIC (/d)
3800,Le .1. (d] 1 1 l \'V yl1 J —{H.`-�y—
Policy No. I I�C erly /ally
/yy�r�."I tad opv i,Hereby tumished. TOteI
LI Venifiaof copy is filed with the city inspection division.
Applicant
CERTIFICATE OF EXEMPTIONFROM WORKERS' N.C.
D 0 PERMIT AUTHORIZATION DATE
COM PENSATION N S URANCE
(This,action n d not be completed it he Permit is for one hundred doL `/vMq/)
Ian 16,001 or lessthat
in C/ co/
1 c•00) tn,t n me pa.fofinence of he work for which his permit is
+arid, I mess not employ any parson any manner so as to become subject
to the Filly
Compensation Law.of California.n
Data Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
You should become oublact t0 the Work.,.'Compensation provisions of the
Labor Coda, you must forthwith comply with such Provisions or his permit
shell be deemed revoked. All roofsshell be Inspected prior toany roofing material being
I certify mat I naw road this application and vale that the above informs Installed If a roof IS installed without first Obtal Ing an
tion is .."act. I to building to comply with all city and county ordinances and lnapeCtlOn,l agree tol re OVr/1 e'all n@w meterlalgfo�r int eCt R
,iib saws relating to hi , pconstruction, and hereby authofor spresenn IfWVA !fv/l/ �-1
talipes of this city t0•nbr upon ma abovemantionatl PrOpattY for impaction
Purpose..will
(Wel fibrae n, udg indemnify and expenses
harmless Which me City of ay accrue
against liabilities,judgments,costs and gr poise. f this may in any way accrue
•wm,t 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