R-4097I
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OFFICE COPY
PERMIT R_ 4097
Rea
APPLICATION FOR CITY OF CUPERTINO NUMBER
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
EXPIRES IF OT STARTED
WIRMIT
WORK IS THIN 180 DAYS OF PERM TISSUANCE OR
(408) 252-4505 EXT. 228
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
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IoLkl�'+�J \ Ll j
RESIDENTIAL COMMERCIAL OTHER
WNER'S
QJ404
HAZARDOUS ROOF
NAME Y'r 't
FIRE COVERING
AREA CLASS
EXISTING ROOF COVERING
ODRESS a S
O —T
� 5
NUMBER OF EXISTING COVERINGS
PHONE 1 /
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S
' w
6w
TYP OF ROOF COVERING
NAME
RE
CDD
IT as
EXISTING
BUILT-UP ROOF
PHONE
ASPHALT SHINGLES
LICENSE
NUMBER
OODSHAKES
LICENSED CONTRACTORS DECLARATION
I hooey affirm 7000) licensed under provisions of p (commea
clop with Section of DF d Plot
eff 3 of the Business end P,pLaiOpa DOtl•,
LES
full f rc
and my Iiia. la In full forte and ailette
d
ence Clan Lic. Number
OTHER (SPECIFY)
O
Da. comracm.
OWN ER BUILDER DECLARATION
1 hereby affbm the, I eexempt nom the Contractor's License Lew for
PROPOSED
,he following reason. (Sec. 7031.5, Business and Professions Code: Any city
or county which requires a permit to construct, alter, improve, aamolish,or
,.pair any structure, prior to its iso nc also requires the applicant for such
BUILT-UP ROOF
Palm,1 tP file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Profession, Codel o, that he is exempt mare
ASPHALILHINGLES
from and the basis for the alleged exemption. Any violation of section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of nor more that rive hundred dollen ($500).):
WOOD SHAKES
❑ I, as owner of the property, or my employees with wages as their sola
compensation, will do the work, and the structure is not intended or otl.r.d
for ..to (Sec. 7044, Business and Professions Code: The Contractor's License
Lew don not apply 10 an owner of property who builds or improves thereon,
and who does such work himself or through his own employees, provided that
such improvements are not intended or offered for fele. If, however, the
OTHER (SPECIFY)
bulling or improvement is sold within one year of completion, the owner
builder will nava the burden of proving that he did not build or improve for
P.,Pos.of
PROVIDE I.C.B.O. REPORT NO.
❑ I.as owner of the property, a exclusively contracting with licensed
contractors to construct the project (Sac. 7044, Business and Professions
CodeThe
: The Contractor's License Law does not apply w an owner of property
PROVIDE MFGR. INSTALLATION SPECS.
who P improves theroun, and who contracts for such projects with a
contractor(,) IicanNd pursuant to the Contractor's License Law.
reason I .m ...mgt goer, sec. ,e.aP.c. for this
APPLICATION DATE
VALUATION
is PERMIT FEE
Owner Dote
WORKERS' COMPENSATION DECLARATION
Building
o a tali
I 'a of .Hires that I nave i certificate of concent to copy
of00 01 Workari Compensation Insurance, or a canisiatl copy lheraof (sac.
PA
Seismic
3800, LabNo. C.I.
Policy No. Company
is
8 c.run.it copy is hereby Ipmgned. /
/�
Total
Certined copy n filed with m: city inspamion dNision V
l�%
Applicant
RMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' C�n,
N.C. ❑ '! U
Li/ ~
COMPENSATION INSURANCE f
(This Section need not be completed a permit if for one hundred dol
aH m
tire ($100)) or or less.).
FH/Jl
1 certify that m the performance of the work for whites anis permit is
V
person
issued, 1 shall not employ any person in any manner so as to become subject
to Ina Workers' Compensation Laws of California.
.I1'•!
Data
APPLICANT:
NOTICE NT: If., oho making this of Exemption,
should Compensation Provisions of ma
You an Ould become o tna Workari Csuch
pr visa ns
Code. ropes forthwith pPmofy with such Pmm,lom or this permit
st fort i
All roofs shall be Inspected prlortoany roofing material being
eyou
.hall
anal) b. doomed revoked.
I certify that I have rose this sppliu[ion and stn. that the above inform.
Installed. If a roof is installed without first obtaining an
tion is correct. 1 agree to comply with all city and county ordinances aneinspection,
I ogre to remove all new ma erials for inspection.
net. Iawf rel.ting to building construction, and hereby authorize rapreem
,&lives of this city to enter upon the above mentioned property for inspection
-
t
papcaes.
(We) agnea to sive, indemnify and keep n0rmlaes the city of cppo0lno
A,,: _ >
again iabiliitI" judgments, costs and expenses which may in any way •«rue
against +aid ctry in consequsnw of the granting of mi+parmi7.
SIGN TURE OF APPLICANT D TE
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
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