R 4179 (2) PERMIT
APPLICATION FOR
CIN OF CUPERTINO NUMBER R- 4179 '
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN IE80 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
'
BUILDING ADDRESS
BUILDING USE
Nelligg
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME
_ FIRE COVERING
''11� C',, f �f � AREA CLASS
ADDRESS QTD a.lC-.1.� ill ICJ• /`�Yl� ,/ EXISTING ROOF COVERING
PHONE S - ,Lm -.;L6 3- cbD I4 NUMBER OF EXISTING COVERINGS
ON
NAME l �.Q/ Il .- / ! I t-((� lk'�}f'1✓(� TO BE REMOVED TO BE RETAINED
1 �--�— �—� TYPE OF ROOF COVERING
ADDRECITY III rlflto 1�'lC,(�1tnC.¢�.�. I1.�_i _ EXISTING
04"PHONE ' �(p �7� � O BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER 6 NO 2_4e
WOOD SHAKES
Lm that ID CONTRACTORS under DECLARATION
I hereby affirm that I am licensed undo provisions of Chapter B 1 ommem
ting y Il section 7I of Division 3 of the Brines yea fl Coea, WOOD SHINGLES
ma my h Sete b In 1 1 t anis affect �!
Llcenb 1OZ Ccn,r t., ,Qt_ OTHER (SPECIFY)
Deb 0omrector
OWNER-BUILDER DECLARATI N ��
I hereby affirm that I em exempt from the Contractor's License LAW for ljD
the following reason. (Sec. 7031.6. Business and Professions Code: Any city PROPOSED
or c..MY wnich requires A permit to construct, ,e11. Improve, demolisher, c
repair any ft,uctur.,prior to its issuance,also requlrn the applicant for such BUILT-UP ROOF
Permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor'l LIF.nse Law (Chapter 9 (commencing with Section 7000) ���y —
of from and the basis for the alleged exemption. Any violation of Section Division 3 of the Business and Profession.Cod.)or that he is exempt mere ASPHALT SHINGLES•L
7031.6 by any applicant for a permit subjects the applicant to a civil penalty �"L
of not mon that five hundred dollars($500)J: WOOD SHAKES HgNO
❑ I,as own., of in.property, or my employees with Wage,es their sola
fpm pensation,will do the work, and the structure is not intended or oifarotl
for tele (Sec. 7044, Business ane Profession,Code: The ContractorY Licanb D SHINGLES
Lew don not apply to an owner of Property who builds or improve,thereon,
And Who does such work himself or through his own employees,provided the;
such improvements see not intended or offered for sale. If, however, me OTHER (SPECIFY) ro��
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or Improve for -\
purLon of I.J.,aPROVIDE I.C.B.O. REPORT NO.
❑ 1, es owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor'. LitennLaw does not apply toanowner ofproperty PROVIDEMFGR. INSTALLATIONSPECS.
who builds of improves thereun,and who contracts for such projects With e
contractor(s)licensed pursuant to the Contractor's License Law.
❑ I em exempt under sac. ,a.aP.c.for this APPLICATION DATE VALUATION PERMIT FEE
.
..on Own. De,. �M--y,
WORKERS'COMPENSATION DECLARATION Building'
hereby affirm that I have a certificate of consent to nf-insure,or a car 1' _a4-
3800ts of Workari/CompJa}/i tion Inwn (Py'ya�titietl copy)m�are�ot feet. '//�' / ,{/ �/y/� Seismic
3800.Leb. �C Y c .H�r.' �LaeT I �J 5 Pµ.~lyv �(
Po Icy No, o pen C
.need copy i,h.nby with
the it. Total
c.nnise mor Is Nl.a win.m:ary inspection division.
Applicant
CERTIFICATE OF EXEMPTIONFROM WORKERS' N.C.
D 0 PERMIT AUTHORIZATION DATE
COMPENSATION NEURANCE
(This section nn0 not be complete if the permit if for one hundred deb
In.(51001 or Has.)
I certify mat in the performance of the work for whites this permit if
Issuatl. not employ any Lenon in any manner to n to become sublet;
to me Work.,kari Compensation Lam of California
Deb Applicant
NOTICE TO APPLICANT: o attar making this Compensation
p of Exemption,
you rM1Cod become subject to me comply
Workers' Compensation provisions a the
Labor Code,you mutt forthwith comply wiM such provision.or this permit
*hall be deemed revoked. All roofs shall be Inspected priortoany roofing material being
Icertify that I have read thisepplitetion and.teb that theabove inform.- Installed. If a roof Is Installed without first obtaining an
tion is correct. I sone to ng cons rico W cityand And county ordinances re
r and inspe MQ1�I gree to remove a f'n w materiels for inspectlo
nate bus raining to building co construction, end andherebyco ntyori in npmn 11
tetiv-of this city to enter upon the above mentioned property for inspection
purposes.
(Wal agree s, rave, indemnify and expenses
eshermins,which the City pi Cupertino
against liabilities, consequence
cons and upmb.which they in any way accrue
' against bus City th ton.equmte of me q.eminv or mit dermic SIGNATURE OF AP IC N DAT
PRE-INSPECTION: PLYWOOD: IN-P O ESS:
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