R 4126 PERMIT
APPLICATION FOR CITY OF CUPERTINO INUMBEIR R- 412 6
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
• (408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS / - BUILDING USE
3i;-0 G v RESIDENTIAL COMMERCIAL OTHER
OWNER'S
NAME DG�r/c�ic S/.4�.ic S✓L FIRE HAZ?kRDOUS ROOF
COVERING
2 �^ / AREA CLASS
ADDRESS y223.5--6 EXISTING ROOF COVERING
PHONE F 7 NUMBER OF EXISTING COVERINGS 3 2
CONTRACTOR'S
/J D �i ,. / ♦ TO BE REMOVED TO BE RETAINED
NAME �j C� , ` /V fP TYPE OF ROOF COVERING
ADT
DR ZSa kyr, ,(� s L Q�//
L EXISTING
PHONE
BUILT-UP ROOF
LICENSEZ L ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
WimhereS affirm that I of wl.1c a undo provisions of Chapter ....Cod.,
andwith Section 70001 of and affect.n 0 of tote Business ens Probnlons Coate, WOOD SHINGLES
and my llcen,e N in lull Iprca entl L
License Coss Con Numb., OTHER (SPECIFY)
Oen
Contractor
OWNER BUILDER DECLARATION
I hereby affirm the, I am exempt from Ina Contractors License Lew for PROPOSED
the following reason. (Sac, 7031.8, Business and Profession,Coda: Any city
or county which requires a permit to construct, alter, Improve,dem Olisb,or
repair any structure,prior to its issuance,also requires the applicant for such BUILT-UP ROO
of
to file aanatl statement Law that he r Ilcanud pursuant to the 7 00)
pf mi Contractor'.fila signed
Licana Lew(Cather 9 (commencing with Section]0001
of m and
0 of ma Bfor the
and Professions conal or mel he isofS masa ASPHALT SHINGLE
.f D and the basis for the ndallegedPro exemption. Any violation exempt Section
7001.5 by any applicant for a permit subjects the applicant to a civil penalty
of not mora mat five hundred dollen(11500).1: WOOD SHAKES
D 1, as own.,of In.property, or my employees with wages a their sole
compensation, will do the work, and the structure is not intended or offered
for ale(Sec. 7044, Business and Profession,Code: The Contractor's License WOOD SHINGLES
Lew don not apply to an owner of property who build.or improve.thereon,
and who noes such work nit elfint or ed o r o his own employees, however,the OTHER (SPECIFY)MONB//C L/(j/g r(.yC-yGt*'l :
such ng o improv are not old wed or offered for sole. If, however, the
building or improvement is .old within one Year of completion, me owner
purpose
will nava tM1e burden of proving sun nes did not build or improve for
pp 3 1 of.own PROVIDE I.C.B.O. REPORT NO.
I. a owner st IM1a he projecy. t
( axclu 044, Busincontress a with licensed
coca: Thetors to construct ice project does
not
Business o entl .property coag: Tota or improve, License Law who not apply to an such
Pr oft.with PROVIDE MFGR. INSTALLATION SPECS.
who builds or improve. su nt to and who contracts for such projec6 with
contract am lempttlpursu antro the Contractor's License Law.
rax On I em exempt under Sac. ,B.&P.C.for this
Owner Date
APPLICATION DATE VALUATION PE MIT FEE
WORKERS'COMPENSATION DECLARATION Buildin
I hereby affirm that I have s certificate of consent to sal Linturs,or a car.
3800n of Workari Companation In.unnce [illatl pY mercer.(sac.
DBOQ Lo11=- y
/i� .Se18mIC
Policv Noompany J /S (J/{f I/ PAI B
,Cabv sur pe V' W (CJ' - fTotal
ew in.pyt division, a
Applicant / �Qa/x
CERTIFICATE
O NSATION(ION FROM NSURANCE WORKERS' N.C. ❑ ORIZATION DATE
(This section .) not be completed it the permit i.IPI one hundred dal'
Ian($100)or that
i C11 r Uh r r
I <aIsh tnat in me Oany.mance of the work for suntoot this permit i.
toted, I.reel not employ any person In any manner w as to become subject 11k/
to the Workers'Compensation Lew.of California.
Dan Applicant
NOTICE TO APPLICANT: o alter making this Compensation
provisions of Eoof on,
you should D ou me st fort i the Worker'Companation n. r hs of me
Labor Coda,you must forthwith comply with such provision,or this permit
asseAB roofs shall be
Shall be domed.avows, Inspected prior tOany roofing material being
I certify that I hese read this application and stere that the above inibrme installed. If a roof is Installed without first obtaining an
tion is correct. f agree to comply with all city and county ordinances and Inspection,I agree to remove all new materiels for inspection.
sate Iewe relating to building construction, and hereby outhori.e rAprnen. P 4 g P
ta,ivas of this city to enter upon the above mention"property for Inspection
pure Pse..
(We) agree to ave, indemnify and keep harmlea the City of Cupertino
against liabilities,Judgments,con,and expenses which may In any way Kcrue
against said City in consequence of me granting at In is permit. SIGNATURE OF 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