R-3929 APPLICATION FOR PERMIT
CITY OF CUPERTINO NUMBER R-
3929
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WRK IS NOT STARTED
5408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERM T ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
t BUILDING ADDRESS BUILDING USE
162.50 -arw RESIDENTIAL COMMERCIAL OTHER
OWNER's //-
NAME LO rT i HAZARDOUS ROOF
FIRE COVERING
AREA CLASS
ADDRESS / 79-O L0C (C(inn EXISTING ROOF COVERING
PHONE lj _ 6 NUMBER OF EXISTING COVERIN
CONTRACTOR'S
/ r
NAME 44114 T/OPV TO BE REMOVED TO BE REQ INED
T F-ROOF-COVERTIG-
ADDRESS
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CITY&ZIP ?7yG��4&f Dld CIE S�f YtCj 7 G
PHONE I (�- 77-7—/7 s7V / BUILT-UPR OF ✓��
LICENSE
LT S INGLES
NUMBER WOOD SHA ES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed ndo provisions of Chapter 9(<ommem
ting with Section 9000) of Division 3 of the Business and Prof ession+Code, WOOD SHIN LES
and soli Bunn b in r II 1 d and allact.
Llane Clan Lic.Number �f cc�J TT
Date _ �.y .g contractor �. OTHER ISP CIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am e..mpt from the Contractor's License Law for PROPOSED
the following anon. (Sec. 7031.5. Business and Professions Code: Any city
or county which requires a permit to construct, alter, improve, demolish,or
,spelt any structure, prior to its issuance also requires the applicant for such BUILT-UP
permit to file a signed statement that ate is licensed pursuant to the provisions
of the Contractor's License Lew(Chapter 9 (commencing with Section 7000)
Of Division 3 of the Business and Professions Code)or that he is exempt there ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for.permit subjects the applicant to a civil penalty WOOD SHAKES
of not more that five hundred dollars($500).1:
❑ I,as Owner of the property.Or my employees with wages as their sole
<ompemation,will do me work,and the structure is not intended or offered
for tale (Sac. 7044, Business and Professions Code: The Connectors License WOOD SHINGLES
Lew don not apply to an owner of property who builds Or Improves thereon, as
and who don such work himself Or through his own employees,provided In.t
tech improvements are not intended or oifmgd for tele. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, in.owner
builder will have the burden of proving that he did not build or improve for
purpose'. a+own PROVIDE I.C.B.O. REPORT NO.
❑ 1, t Owner st the property, t ( et. 7 44, contractinguseswith licensed
contractors to construct the project pec. t app Businessandand Professions
Cod.: Tats of u Contractor's haroun Lawand who
contracts
for
a such
Pr ofpropertywith PROVIDE MFGR. INSTALLATION SPECS.
who builds )licensed improver su nt t .ted crams for sucF prolecn with a
contract am mptpursuant m me Contractor's License Law.
❑ am exempt undo. sec. ,B.aP.c,for his
tenon APPLICATION DATE VALUATION PERMIT FEE
Ow Date
• her WORKERS'COMPENSATION DECLARATION Building
t. of affirm snot nava i certificate of consent to selfcopy
[her o a ter
silicate O}Worker COm nn\ion Insurance, a certified cgpY tnela0}(Seta O
3BOo, No. c.l,/,�Cl-app mpany fir✓ S If b L Seismic
Policy No. Company (,'/(jEa'7Y MU77J.6L 'e
eCertified copy is hereby furnished. 9,p Total
Certified copy is filed with ma city inspection division. ClR!V
Applicant (r
CERTIFICATE OF EXEMPTION FROM WORKERS' ❑ ( P MIT AUTHORIZATION DATE
N C
COMPENSATION INSURANCE /�//�
(Tab action need not be completed H me permit is for one hundred dpL ('•V
isra 151001 or hot i V
I tarsih \hat in \ata performance of the work for whites mit permit is /!1_
toted, shall not employ any Lenon in mY manner 50 as\O become WOIn\ y1 u)
to the Workari Companastion Lews of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of E.amption,
you should be<Ome subject t0 the Workers' Compensation provisions of the
Labor Code,you must forthwith comply with such provisions or this permit
shell be deemed revoked. All roofs shall be inspected prlorto any roofing material being
I artily Met 1 nave.asd this spoliuron end area that tate above Informs 19telled If a roof is installed without first obtaining an
tion i. correct. I sores to Comply with all City and county orain.n<as.nd sectio IB reetoremoveallnewmaterialsforins action
state laws relating to building construction. and hereby authorize raoresem P g p
Cativo of soh city[o anter upon tate above mentioned property for inspection
purposes.
IWt liabilities.spree save, indemnify antl bap harmless me City of Cupertino
against id ityi Cons a see cons and expenses f this may in any way acvw
against said City in contwuancs of the gaming of this permit S GNATURE OF APPLICAN 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