R-4413 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4 413
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYSOF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
.c// RESIDENTIAL COMMERCIAL OTHER
OWNER'S `
HAZARDOUSROOF
NAME ET'le"1110. ` O"C yV\_1J4 U J0,/`! FIRECOVERING
�
AREA CLASS
ADDRESS aa47,ys[] �a�- EXISTING ROOF COVERING
PHONE o� —/-7ev a) NUMBER OF EXISTING COVERINGS
CONTRACTOR'S L ^
\1FJ-�_C_J TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADDRES
CITY&ZIP \ EXISTING
PHONE
,D$_ aq� - _ I/_ BUILT-UP ROOF
'CJ W `P
LICENSE �S—�/ ASPHALT SHINGLES oZ L.cr.�-A.G�f2-�
NUMBER V YY
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I nether affirm that I of Division
under provisions of dChapterProse s(coon$ ado,
..no with stiction Tocol of Division 3 of the ewinau and vrofnriom cane, WOOD SHINGLES
and sur Ilcanu b In �1�o a affect eel /
License Clast Con Numbs' I V OTHER (SPECIFY)
Data Conerocaor
WNER-BUILDER DECLAflATION =ppgq�-
all
ntinbyQ affirm that I am exempt both the Contractor's License Law fm PROPOSED r�- /�7r IDi
ena rollowin anon. (Sec. 71131.5, Business antl Profession+Code: Any cl[
or county which requires a permit to construct, alter, Improve, demolsh,or —
,.p.lr any sit chits, Prior to its issuance I.. raouirn the applicant for such BUILT-UP ROOF FEB F
la=I to ills a signed statement that he is licensed pursuant to the provisions
of the Contractor's the Business
Lew Professions
s (commencing with Section 71100)
of Division 3 of the Bfor the
and alleged
exam conal or that he is exempt S suer.. ASPHALT SHINGLES
from and the breis for the alleged a emotion. Any violation of Section
TOJ1.6 by any applicant for a permit subjects e applicant to e c penalty
ctf\hlivii l
of not mon mat five hundred dollars($500).1: WOOD SHAKESDG. INSPECTIGN QEPAP.T.c_-..T
❑ I,as owner of the property,or my employees with wages as most sola
.ompenntion, will do the work,and the structure is not intended or offeree WOOD SHINGLES CITY OF CUPERTINO
for tale (Sec. 7044, Business and Profession$Code: The Contractors License
Lew does not apply to an owner of property who builds or improves thereon.
and who does such work himself or through his own employees,provided that
suchimprovement, ere .o[ intended oroffered for sale. R, however, m° OTHER (SPECIFY)
,.;.,I no o mom
ptvemeis sold within one year o1 completion, the owner
builder will nay. he burden of Proving that he did not build of improve for
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
,to,
1, ,f owner of the property. am exclusively contracting wi[n licensee
contactors to
construct the project (Sec. 7044, Business and Profession{
Cod.: The Contractors License Law does not apply to an owner of Property PROVIDE MFGR. INSTALLATION SPECS.
wno builds o improves thenun, and who contracts for such projects with e
ontractor($)licensed pursuant to the Contractor'{License Lew.
c ❑ 1 am exempt under Sac. ,B.&P.C.for this
reason APPLICATION DATE VALUATION PERMIT FEE
Owner Date
WORKERS'COMPENSATION DECLARATION Building
I thereby Affirm thot I have a certificate or consent to self insure,or a car / /�
[i,i,.ta OI Workers Compensation Insure B C(Iilied Cppy��[nersol(Sec. n
3800,Leb.ylLasxf,v( •' \ _ 1 /5 /c Seismic
Policy No. ompany Q e'! sY-
8 co l itid coot i.n .by w.msn.a. Total
ceninea.opv i.m n.ryith m:a[v in nJn a'
APPlice
nt
CERTIFICA OF E%E TION FROM W :ERS' N C ❑ PERMIT AUTHORIZATION DATE
COMPENSATION I NS URANCE
This section need not be completed it the permit '4 for one hundred dol
bat carli or lssithat
i
I ceI shelf
Nat m me perform persnce of nla aork for wn icn eco permit is
issued, {hell of employ any parson in y tenrylr fo es tp become u9j t
to the ante\ion Leeds of C REI
NOTI�L�oLTO-APPLIC Applicant
NOTICE TO•AGFLICAN T: If, a1[er m 'wg [his C 'licata o Exempt io .
You should become subject to the Workers' Compensation provisions of m
Labor Cod., you must forthwith Comply with such provisions of this permit All roofs shallbe eCted flOf to an $00110 material being
shall be deemed r«oked. P P Y g g
Icotify that I have read this application and state that the so...hil.mi Installed. If a roof IS Installed without first obtaining an
tion is correct. I agree to comply with an city and county ordinance and jnS tion,I a tee to remove all new materials for inspection.
.,at. Is. rating to building construction, and hereby sishorize nprhsan. P n, g P
tatives of sub city to anter upon the above mentioned Property for inspection 2 Is
Purpose,. Via m
(We)liabilities,agree 1. uve, in ts,cos s and keep harmless the in a of Cupertino
against fiCiyi cense nn,cons and naganas Which may m my wry accred -
hwimt+via City in conwou.nca of me granting of this permit. SIGNATURE APPLICANT DATE/O;
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