R-4403 (2) PERMIT 4403
APPLICATION FOR CITY OF CUPERTINO INIUMBERRS
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 ORK IS NOT STARTED
WITRI N 1180 DAYS OT EXPIRES IFWERMT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
D, . RESIDENTIAL COMMERCIAL OTHER
OWNER'S _/J{
�,(l(/�L �j/l/.P��yl/.1 � � HAZARDOUS ROOF
NAME FIRE COVERING
CC AREA CLASS
ADDRESS / d 3 —7
�rn`� EXISTING ROOF COVERING
PHONE `Y/' CJ / / NUMBER OF EXISTING COVERINGS _
CONTRAC7
70 BE REMOVE TYPE OOF COVERING
D
NAME /�-�/J T�D,/
COD azih `7 �5 3 7 �x� AeLt9 1 (� EXISTING
PHONE BUILT-UP ROOF
�r SCJ
LICENSE �-+O ASPHALT SHINGLES
NUMBER P l WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(common
ding With S«tion 7000) of Division'3 of the Business and Professions Code, WOOD SHINGLES
t and my IICeme b full f •and affect, r�
! Licmu A ` Lca Number l Q .�j
-. n fId �kq-�n� CiIN or OTHER (SPECIFY)
Data
OWNER-BUILDER DECLARATION
I hereby affirm the, I am exempt bpm the Contractor's License Law for PROPOSED
the following reeson. (Sec. 7091.5, Business and Professions Code: Any city
or county which requires a permit to construct, alter, improve,demolish,or
repair any structure.Prior to its issuance,also requires the applicant for such BUILT-UP ROOF
Permit to file•signed statement that he is licensed pursuant to the provisions
of the Contractor i License Law (Chapter 9 (commencing with Section 70001
of Di.islon 9 of the Business and Professions Code)or that he is exempt there ASPHALT SHINGLES YN
• from and the basis for the alleged exemption. Any violation of Section
7091.5 by any applicant for a permit subjects me applicant too civil penalty
of not more that five hundred dollen($500).1: WOOD SHAKES
comI, as owner of the property, or my employees with wages as their FDIa
pensation.will do the work, and the structure is not intended or offered WOOD SHINGLES I"s r^
for sale (Sec. )044, Business end Professions Coda: The Contractor's License
Law don not apply to an owner of property who builds or improves thereon, D
end who does such work himself or through his own employees,provided that ILLVs
Such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY) AUGU
bu lain, or improvement is sold within one year of completion, the owner
builder will have the burden of Droving that he did not build or improve for NU
Purpme,f nl..l' PROVIDE LC.B.O. REflBf7LFNOFtFilll
I,
as owner of the property, am exclusively contracting with licensed
contrac ton to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Low does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
win o builds or improves tnaroun,and who contracts for such projects with a
contractor(&)licensed pursuant to the Contractor's License Law.
O 1 am ...mot under Sec. ,B.&P.C.for this
own. Dat.
APPLICATION DATE VALUATION PERMIT FEE
WORKERS'COMPENSATION DECLARATION Building / I/ yv
I hereby affirm that I have a certificate at consent to sell.Insure,pr ser
tiff LeI Cd keri Compensation Insurance,or a certified copy Mareof(Sec. 4/C `775 /� Seismic too
38DPolicy No. Company ! / T e
Certified Copy is hereby furnished. Total
o Certified copy is filed with me c ty inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N C ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section head not be Comr letad if the permit is for one hundred dol. /
I...($100)or las..)
I certify that in me performance of the work for which Permit
issue0 0)d, I s II of employ any par.on my mann r s as[o con•aubj (U�
to[n anutlon Laws ie
Dau Applicant zralcLid
NOTICE TO APPLICANT. If, after making this ificate of xamptlon,
You should become Subject to the Workeri Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
shell be doomed revoked. All roofs shall be inspected prlorto any roofing material being
I Certify that I have road this application and state that the above inform.. installed. If a roof is installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinances andstate inSpeCtlOrF.ttt���8 t0lem�/OV//e/�^$II OBW materials fOflR peCtiOM1
Tiv Lew. resting to enter
building construction, mtl ned pr authorize npresem �(`--�7F'y ✓�
Utivo of this city to mtar upon She above mentioned property for inspection
purpose'.
IW 1 agree liabilities, sever, indemnits and keep harmless the City q1 Cupertino
against saidityi judgments,coats and expenses which mem in any way accrue
.,•inert silo DItV in consequence of the granting of this permit. SIGNATUREOF 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