R-4106 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R 410 6
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERM T NOT
OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ` .,.,�.\ - BUILDING USE
"T� F- CLQ i RESI DENTAL COMMERCIAL OTHER
OWNER'SHAZARD`` (��< }yam
ROOF
NAM"'y+fM\Y\0"i � C' `e-n FIREAHLOUSUV CLASS ING
ADDRESS �f �\ y V e__ EXISTING ROOF COVERING
L�
PHONE —`U � �-� NUMBER OF EXISTING COVERINGS
n
CONTRALTO 'S ,
TO BE REMOVED TO BE RETAINED
NAME C\L TYPE OF ROOF COVERING
CITYADDRBESSSp `D&O ` \A027A'�t_s.�n� J EXISTING
PHONE��h 3�2CI ���' �l BUILT-UP ROOF
LICENSE y _�T �_� ASPEHINGLES
NUMBER LSt 1 LICENSED CONTRACTORS DECLARATION
I h.,rlby."firm the,I am licensed nder prmbiom of Chapter 9 fcommem
ung with Section70001 of Divi.mh a of Na Bu.inas.and Prof...ion.Coda,and mylicense is In full force and e1/a<License CIm Lic.Number 0T
De,. Contractor fPv
OWNER-BUILDER DECLARATION 14�� 9 4
I hereby affirm that I e exempt from the Contractor's License Lew for PROPOSED
the following reason. (Sac. 7031.5, Business and Professions COCA Any city ^/ t N12
or county which requires a permit to construct, alter, improv., damolisb,or 4 ! J99�
.pair anv structure,Prior to Its issuance,also requires the applicant for such gUl LT-UP ROOF1r
IF*= to fila a signed statement that he Is licensed pursuant to the provisions LoFC
of the Contractors License Law (Chapter 9 (C.mmancing With Section 7000) Lo
'k.
Division 3 of Ma Business and Profn$iom Code)or that he is exempt there. ASPHALT SHINGLES h7gV(-
from and the basis for tha allagetl exemption. Any violation•of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
Of not or.That five hundred dollars(Ssom.l: WOOD SHAKES
❑ 1.as owner of the property, or my employees with wages as their sola
compensation,will do the work, and the structure is not intended or offered
for..I. (Sec. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
Lew dos notons such to an owner of property gh who n em to improves thereon, ��
and who does such wart himself or through his own employees,providedover the tont
such improvements • not intended p Offered for sale. II, however, the OTHER(SPECIFY)
building or improvement is sold within or
year of completion, the owner
builder will have the burden of proving that he did not build or Improve for
purpose of sole.). PROVIDE I.C.B.O. REPORT NO.
L3 I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: TheContracto:sLicense Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or
mproves [4eroun, and who contracts for such projects with a
contractor($)li tensed pursuant to the Contractor's License Law.
❑n I nm •=•mot orad., sap. ,Baa P,c.for this
ea APPLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I nava a certificate of consent to sell.insure,or a car
tificate of Workers'Compensation Insurance,or acertified copy thereof(Sac. Seismic
3800,Lab.C.).
IIS
Polio N:. CompenY
8 Caroli rab,furnished. I Total
Certifi co f ad with the city inspection division ISh/
Applicant ��
CERTI CTE OF EXE
P INSURANCE
R
ON FROM ORKERS'\ `, k-t PERMIT AUTHORIZATION DATE
(This section neatl pppot be completed it the permit is for one hundred dol
Ins 191001 or lns.li /
I certify Nat he performance �I w k for whico this permit is
issued, 1 serail t. Ioy any person i •\ her sa es to bacons.subjac[
to the W rkari ons ansetion Laws of rtf i .
O.ta Applicantor
NOT( 1 NT: If, aft., mak [Ns Certificate o1 Exemption,
you Nou atom wbj.t to the Work.,. Compensation provisions of the
Labor code, op must forthwith comply with such provisions or this permit All roofs shall be inspected prior to any rooting ateri being
$h.1 be domed revoked.
I ... if, Nat I have .ad this application and state that the above inform. installed If a roof is installed without first obtaining an
tion is correct. I agree to comply with .b city and county Ordinances and I ectl n,I agree to remove all new materials for inspection
state laws relating to building construction, and hereby authorize npr..n (\insoe) IA1,1 //�,I -7
Purpoiv.se
of this city to.our upon shabove-mentioned property fpr inspection a../ /C�� /9
pw(We)
(We)liabilities.agree so save, indemnify antl keen es whi h N. City pt C ---no
againstid iyi consequence
tett and expenses which may in any way accrue
against said City in conwquanpe o1 me granting of this permit SIGNATURE OF APPLICANT OATE
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