R-4192 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4192
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERM TISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDREF`SSSS�'J, �� �/�.�y�) - BUILDING USE
"�.JIJ E/ Q assESIDENTIAL_ COMMERCIAL OTHER
OWNER'SorHAZC„
ROOF
NAME �6 L cg_-r �G/1/DF_ RrS01� FIREARDOUS , ek _ COVERING
/ q AREA 'l�(Y/] CLASS
ADDRESS EXISTING ROOF COVERING
PHONE O Ei �j� — NUMBER OF EXIS ING OVERINGS
CONTRAC R'S /�
3 E, ✓2�d6��9.✓��a/' /i✓L- TO BE REMOVED TO BE RETAINED
NAME -
/� � / TY OF ROOF COVERING
ADDRESS
IDTV a Zih \,c .T (! !'�-f' /lfGl�.D EXISTING
PHONE�e�k ���T BUILT-
LICENSE
SPH T SHINGLES
NUMBER jClp ��
WOOD SHA(
LICENSED CONTRACTORS under DECLARATION
I hereby attires the I of Division
3o f t Provisions of dChapter s(common.Code
Ping with Section 1D001 force
Division 3 or the Business ma Pnbn;ons coda, WOOD SHINGLES
and my Ci license b in full force ane affect.
DLI ata
Cba Lic.Number
erase convxtor OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractor's License Lew for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
OI county which requires a permit to construct, altar, improve, dimalish,or
repair any structure.prior to its issuance.also requires the applicant for suchBUILT- OF
permit to fila a signed statement that he is licensed pursuant to the provision,
of the Convector's License Lew (Chapter 9 (commencing with Section 70001
of DIVI'100 3 of ma Business and Professions cotla)or that he;...amp+me.. ASPHALT SHINGLES
from and the basis for the ellegad exemption. Any viob[;on of or
7031.6 by any applicant fore Permit wbjecn the applicant to a c vis penalty
of not mon[net five hundred Collars(5500).1: WOO
D I,as owner of the property, or my em Plovam with wages of[hair tole
com rmustion,wise do the work, and the structure is not intended or offeree WOOD SHINGLES
for tela(Sec. 7044. Business and Professions Coda: The Contractor f License
Law do"n0+ apply to an owner of property who builds or improves thereon,
and echo Coes,wch work himself Or through his Own employees,provided that
such improvements are not intended or offered for tale. If, however, the OTHER (SPECIFY)
bWlding o mprovemant is sola within one year o1 completion, the owner
builder will have the burden of proving that he did not build or improve for
PurposeOe'ela.l. PROVIDE I.C.B.O. REPORT NO.
0 I, s owner of the property, am exclusively contracting with licensed
contractor' to c nstruct the project (Sac. 7044, Business and Professions
Code: TheConbxmr'sLicense Law does no,apply toanOwn.,ofproperty PROVIDEMFGR. INSTALLATIONSPECS.
wh0 builds or improve'thereun, and who contncn for such Projects with a
contractor( I licanted pursuant to the Contractor's License Law.
aeon l .m exempt under s.C. ,B.aP.c.10r mit APPLICATION,DATE VALUATION PERMIT FEE
Owner Data vN U
WORKERS'COMPENSATION DECLARATION Buildin
I hereby artier the[ I ehavensa i n nsuran of content io selfcopy
the,o �I
silicate of Workers Compensation Insurance,or a car Ffietl copr meraof lSac. CUL ] 19 $alamlC
3800, No.Labcele 1
Police No. Company ryI .
h]] Certified top,I.hereby furnished, '1 1 Vr Total
certified copy is filed with the city inspection division. (J /-/ r
Applicant �r�H( (z
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
C ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed it the Permit if fere ossa nu ndretl a06
fan 151001 or lan.l
I certify
that in ma performance 01 [fie work fere which this permit
25)
issued, I shall not employ any parson in any mann er to a to become subject
to the Work.,.Comp ennti.n Laws Ot California,
Data Applicant
NOTICE TO APPLICANT: 11, after making this Certificate o1 Exemption,
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such Provisions or this permit
shall be deemed revoked. All roofs shall be inspected prior toany roofing material being
1 Certify that I nave read tni..PpfiC.ron end stet@ that the above informs installed. If a roof is in is ad without first obtaining an
tion is correct. 1 •gree m comply with all City and county ordinance.and inspection,I agree oveall new materielsforina act
vee laws meting to building construction, and harebv outhor4if rrionlim
'alive of this city to enter upon the above mentioned property for inspection
Purpose.
(We) ogre t0 eve, indemnify and keep harmless the City of Cupertino
:against liabilities,judgments,costs and expenses Which may In any way accrue
p mI,aid City;n consequence of the granting of this Permit. G APPLICANT DAT
• 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