R-4144 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERRas 4144
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PIOT STARTED
TH if 180 DAYSOFEXPIRES IF P RMIRK T�SSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
MBUILDING ADDRESS BUILDING USE
1 �bS 1;-16 61mi S/ RESIDENTIAL COMMERCIAL OTHER
OWNER'S / /J
LA/eZl ���/� L� FIRE
NAME COVERING
AREA CLASS
ADDRESS. EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
�dOF/� r TO BE REMOVED TO BE RETAINED
NAME C. fJ /�- Cy CX/ TYPF OF ROOF COVERING
ADDRESS
CITY&Zip �1S�o /'dOT/t�L L �y�
EXISTING
BUILT-UP ROOF
PHONE
LICENSE ASPHALT SHINGLES
NUMBER 6 L WOOD SHAKES
LI CENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under Provisions Of Chapter 9(common
ing with section 70001 of Division 3 of the Business and Professions cod.. WOOD SHINGLES
and my license le in �I for affect.
oat`en`ec u — Co^IN�[�Der 6 , o /��/(� �THER (SPECIFY)
OWNER BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor'+ License Law for
the fallowing reason. (Sec. 7031.5, Business and Profession+Code: Any city PROPOSED
or county which requires a permit to construct, sitar, improve, demolish,or
repair any structure.Prior to its issuance. also requires the applicant for such BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the orovi.ion,
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Coda)or that he is exempt there ASPHALT SHINGLES
from and the anis for tlu .Ilogetl exemption. Any violation of Section
)031.6 by any aPPll<en\ fore permit subjects the applicant to a civil penalty n ��
of not more that five hundred dollars( 5001.1: 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 a offered
for sale (sec. 7044, Business and Professions Coda: The Contractor a Licente WOOD SHINGLES
Lew does not apply to an owner of property who builds or improves thereon.
and who does such work hirn"If or through his own employees,provided the,
such improvements are not intended or offered for sale. Il, however, the OTHER (SPECIFY)
building or improvement sold within one year of completion, the owner
builder will have the burden OI proving that he did not build or improve for
Luo 1 of.own PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner OI [M1s property, a exclusively contracting with licensed
contrecmr+ 10 construct the project (Sac. TOAs, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property PROVIDEMFGR. INSTALLATIONSPECS.
who builds Or improves ther.un, and who contracts for such projects with a
contractors)licensed pursuant to the Contractor's License Law.
❑ I am exempt under sec. sea P.c.for this
meson APPLICATION DATE . VALUATION PERMIT FEE
Owner Do,. r a
WORKERS'COMPENSATION DECLARATION ® Building
I hereby affirm that I have a certificate of consent to self insure,or a car.
[ificeb of Workers'Compensation Insurance, certified copy thereof(sec BBIamIC 1"
3300.
Lab 1. p` ' y�W5� -�. /� JUIN 1
P IicY N�rlJ.�/l.0 Company �tC �
2[C tifiotl copy s hereby furnished. y�tpat Oo y (44 'p Jt fTY Total
-Q t.r,iR.griapy i*I;I 1,,M1y1i(/fr /J/yL f an. i/�s Uh Lur U `rl
APPIicml C:Lr�IJ /�- Ll(/
CERTIFICATE OF EXEMPTION FROM WORKERS' N C ❑ PERMI A'THORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dol
bas($100)or lass.)
I certify \not in th• performance person of the work for which this permit is v
mad,Wno"ork.,,'
not employ any Lenon in any manner to as to become subject
to the Workari Compensation Laws of California.
Data Applicant as
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you should become subject to the Workers' Compensation Provisions of the
Labor
Code, you must forthwith comply with such provisions or this permit All roofsshall be inspected prior to any roofing material being
moll ba deemed revoked.
1 ...iffy that I nava read this application and at.,.the,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 inspection,I agree to r, o all new materialsforinspection.
+4te laws foisting to building construction, and hereby oven o rite repreesn
tativat of this city to enter upon the above mentioned property for inspection
pulp....
(We)
agree to save, indemnify and keep harmless the City al Cupertino �� 3
•,eines AbOiHos,judgments,costs and expenses which may in any way accrue
against said city in consequence of In.yrs di.,of this oarmn. SIG ATUR C//APPLICANT D E
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