R-4131 (2) r•: PERMIT R_ 4131
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408 PERMIT EXPIRES IF WORK IS NOT STARTED
U WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
V
BUILDING ADDRESS , r BUILDING USE
I I J 1 CA� �g e-v- -Q C 1� RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZNAME R-- MIS vvy I�LJ.S FIREARDOUSY 1 COVOERING
AREA �,/ CLASS
ADDRESS I I a-S9 Pa L.oS C1 e✓Q Cil• EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERGS /
CONTRACTOR'S V/
/�A��P�.- TO BE REMOVED TO BE RETAINED
NAME �/�(� TYPE OF ROOF COVERING
ADDRESS ? C—n t ,, n
CITYADD &z16?-70QX L35J (J3 F"I�n�P SP.YP.tnO �I E�30 EXISTING
PHONE,/ 7-6M BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 k.o.by affirm that I em licensetl uttl.r provisions of Crept 9(commeo-
ciny with Section 7000) of Division 3 of the Business and Prpfeai n.code, WOOD SHINGLES
and my ucmee b IF'f-ff)q.and.ffact. nZLi Z
License Clea l\ _ 1))``1I Lic.Number
Data Contractor OTHER (SPECIFY)
OWNER.BUILDER DECLARATION'i
I hereby affirm met I am exempt from rn. Contractor's License Lew for PROPOSED
the following reason. (sec. 7031.5, Business and Profession.Cod.: Any city
or county which requires a permit to construct,altar, improve, damalish,or
rattler.am structure.prior to its issuance also requires ma applicant for such BUILT-UP ROOF
tlomit to lila a u9ned statement that he is licensed pursuant to ma provisions
of the Contractor's
antrecroi• Licams Law 1 "enter 9 (commencing with Section 7000)
of Division 3 of tea B...nea and ofenbm Codal or that he Is exempt therm ASPHALT SHINGLES
from end tea bare for
a aIle ed exemption. Any violation of Section
7031.5 by any app" ant or e p rmit subjects ma applicant to e civil penalty
of nor more to.t fly, nun ,add lar ($500).1: WOOD SHAKES
❑ I,as owner o thres a sola
In. rope ty, my employees With wagtheir,
compenution,will o th wor s the structure is not intended 0,offered
for sale IS... 7044, Bua ass d fessiuns Code: The Contractors license WOOD SHINGLES
Lew eon not appl to or t roperty who builds or improves thereon,
and who don wcn hl If r t rough his own employees,provided the �� !!
such improveman int or offered for sale. If, however, the vUTHER (SPECIFY)
building or Imtlro e a t f sol n one year of completion, the owner.
builder ell.h a bur o prow in that he did or build of improve for �--•�,
curpaa of aale.l. PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owoaf of m property, am exclusively contracting with licensed
contractorsto construct the project (sec. 7044, Business and Professions
Code: To Contractor's License Law does not apply to an ow of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves mansion,and who contracts for such projects with a
contractor($)licensed pursuant to the Convector's License Law.
❑ I am exempt under Sec. ,B.&P.C.for this
..... PPL C I ATE VALUATION PERMIT FEE
Owner Data—
WORKERS'
D
WORKERS'COMPENSATION DECLARATION IesB Q� �are� Building I "l�
I neraby affirm that 1 nava tificate of consent to self insure, JAN 2 R-1'9
tificate of Wor. m [ ca,OIre a tified copy thereof(Sac. VVV fi
3800.Lab.C.1; n, 4pg ')In Seismic
Policy N� .111 'Tl Fumed CrTY OF CUPEHTINO ��
oo--c litre pv�.ha'.by mad. Total
prCer fi a tlr ie filed ate ctryy��gqsp�� tion division. r
Applicant /ltr0 a r f(.�Jf/Vl�—
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT AUTHORIZATION DATE
COMPENSATION I NSU RANCE N.C. 0
(This section need not be completed if the permit is for one hundred dol /1
lar$(5100)or lesf.) 1 ys
I certify the in the p.,Iarmance of the work for which this permit is
iI mall not employ any parson in any mannter so as to become subject
t0o the the Workan'Compensation Lam Of Glilornia.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you should become subject to the Workers'Compensation provisions of the
Lebor Cod.,you must forthwith comply with such provisions or this permit All roofs shall be inspected prior to any roofing material being
shall be deemed reeok.d.
I certify Mat 1 have read mite apph..tian and cit.that,h.above inform. installed. If a roof Is installed without first obtaining an
tion is correct. I agree to comply with aD city and county ordinances and inspection,I agree to removeall new materials for inspection.
i/ $rat• lawn hilarity to building construction, end hereby pr fetoo fora spraem
n tetiv.1 W this city to enter upon the raboveuctio ,mentioned and
property for inspection
G purpose$. •/{'��� / �''3�^� �a
gyp (W.I agree to save, indemnify and keep harmless the City of Cupertino PI�i d ( -Oy /
against liabilities,judgments,costs and expenses which may In any way accrue C
44
eeainst said City in consequence of the granting of this permit. SIGNATURE 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