R-4145 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 414 5
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
•. 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS 5 r\ n BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
NAMt/ S J� 1 L / /( Z°/ll FIRECOVERING
ARDOUS ROO
L t� AREA CLASS
ORES$ �n �Q? f-- f��04� LLIL EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S
N _ TO BE REMOVED TO BE RETAINED
/JIB ,7.61" _ TYPE OF ROOF COVERING
PIT
PHONE �-/ �C G Ito =BUILT-UP
LIC SE / �./P C' PHALT SHINGLES
NU BER J C_ WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commem
sing with Sactlon 70001 of Division 3 of me Business and Professions Code, WOOD SHINGLES
and my license b In full force and affect.
License Cie._ U..Number
D... Contractor
OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm that I .m exempt from the Contractor's License Lew for PROP
O
the following reason.
(Sec. 7031.5, Business and Profession*Code: Any city
or county which requires a permit to c nstruct, alter, improve, demolish,or
r.P.ir ny structure,prior to its issuance,also reouire. he applicant for such BU I LT-UP ROOF
Permitato file.signed st.t.ment that he is licensed pursuant to the Provisions
of he Conv.cmi• License Low (Chapter 9 (commencing with Section 7000)
fromDivision 3 of ma Businessfothe all ged ex ons tion.or that he i.exempt[heli n T SHINGLES
from end me befit for ma alleged seams Cron. Any violation of Rection
]031.5 by any applicant for a permit subjectsme applicant to s civil penalty
of not more the,live hundred dollars($500).1: WOOD SHAKES
❑ I'as owner of memee
•proper,,, or my ploys with wage,as their sole
sa
compention,will do he work, and the structure I. not intended or offered WOOD SHINGLES
for Sale (Sec. 7044, Business end Professions Code: The Contractor's License
Law does not apply to an owner of property who builds or improve%thereon,
and who don such work himself or through his own employees,provided that
bcash improvements are not intended or offered for sale. IT. however, the OTHER (SPECIFY)
uilding or improvement i, sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
purpose of faia.l. PROVIDE I.C.B.O. REPORT NO.
❑ I, n owner of the property, a exclusively convecting with licensed
contractors to construct the Project (Sec. 7044, Business and Professions
Coda: The ComratIm's License Lew does not apply to an owner of Property PROVIDE li INSTALLATION SPECS.
who bunds o mprove$ the euA, and who contracts for such Projects with a
convanor(e)of
pursuant to the Contractor's License Law.
❑ am exempt Peder sac. ,Bea P.C. for this
I...on APPLICATION DATE VALUATION PER FEE
Owner D.nS
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I have a car,ificate of consent to self insure,or a car
tific ve of Workers'Compensation Insurance,or a certified copy thereof(Sec. PAID l O<1 seismic 3800,Lab.C.1. Vf" M 9 K
Poll cv No. Company lib
c Certified copy is hereby furnished. Total
Certified coo,is filed with m:city inspection division. 0
Appl ic.m 1r
CERTIFICATE OF EXEMPTIONFROM WORKERS' N C PERM IT AUTHO RIZATION DATE
COMPENSATION N S URANCE
(This section need not be completed if the permit is for on.M1Pndred dol - I T'Ut IdUYtti I INU
lar*($100)or iesf.l -- (p
I certify that in the performance of the work for which this Permit is
issued, I shell not employ any parson in any manner so as to become fu bjact
to the Workers'Compensation Laws of California.
DaSa Applicant
NOTICE TO APPLICANT: If, after making this Cer,ificatm
a of Exeption,
you should become Subject t0 the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit All roofs shall be Inspected prior to any roofing material being
shall be deemed revoked.
d.rmy that I have read this application and nate that the above inform._ Installed If a roof Is Installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinances and IOSpeCt10 gree lO femOVe eW meterleS rlSpec IDR
nate law, relating to building construction, and hereby authorize reorsen /
,.lives of this city to enter upon the boy.-mentioned property for inspection
pulp.....
(We) agree to ..... indemnify and keep harmless the City of Cupertino
against liabilities,judgments,cons and expanses which may in any way accrue
against said City in conseatance of me granting of this Permit. IGNA RE F PPLICANT DA E
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 _