R-4125 (2) PERMIT R_ 412 5
APPLICATION FOR CITY OF CUPERTINO NUMBER
R.
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
(�OB)252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - BUILDING USE
/ ` J e �79 RESIDENTIAL COMMERCIAL OTHER
OWNER'S//✓�
_ !� moi' •%P rte , �}� HAZARDOUS ROOF ANAME
FIRE COVERING
AREA CLASS
ADDRESS. Z_4;� c7i) G /7�"� EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S r c
NAMEl�i.. J�/ / ' TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
ADDRESS
CIITY&ZIP �/ 7i I� /J ��
EXISTING
PHONE BUILT-UP ROOF
LICENSEiS r ASPHALT SHINGLES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION `
I hereby affirm that I am licensed under provisions of Chapter g(common
Bina with Section T000) of Division 3 PI me eu$In... n .�ayy�y°d.. WOOD $HING LES
end my liana I.in dl fort aM�llaco
Do,.Lh:o — F, Contra for 6 0 OTHER (SPECIFY) P A 1 P1
Dm - Contractor /'�Y
OatIa ILOER DE the RATIO
herby affirm that I . exempt ngm the d Contractor's License Lew for PROPOSED 'JUL -
tha following moon. (sac. permit,to construct,
and Plter. improve,
Code: Any city Is Q(�a.p
or county which requires a permit to comtsucL allay, improve, demolish,or ly7yVR.
repel any structure,Prior to its issuance, also requires the applicant for Such BUILT-UP ROOF CITY LUr.]
permit to fila a signed statement that he Is licensed pursuant to the provisions EkffNO
of the Contractor's License Lew (Chapter g (commencing with Section 7000)
o1 Division 3 of the Business and Professions Code)or that he is exempt mere ASPHALT SHINGLES
from and
the basis for the alleged exemption. Any violation of Section
7031.5 br enV applicant for a Permit subjects the applicant to a civil penalty
of not more met five hundred dollen Is800).): WOOD SHAKES
❑ I, n owner of the property, or my employees with wages es their sole
compensation, will do Sha work,and the structure if not intended or offered
.or ale(Sac. 70,40, Business and Profession.Code: The Contractors License WOOD SHINGLES
Law does not apply to an owner of Property who builds or improves thereon,
and whodo.Such work himself or through his own employees,provided that
such Improvement+ are not intended or offered for fele. If, however, the OTHER (SPECIFY)
buldino or improvement sold within one year of completion, me owner
builtlor will have the burden of proving that he did not build or improve for
Purposeolsal..). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, a exclusively contracting with licensed
contractor. to construct the Project(Sac. Topa, Business and Profevion.
CodContractor's
e: TheLicenseLawdoesnorapplytoanownerofpropany PROVIDE MFGR. INSTALLATION SPECS.
w,0 builds or improve$ thereon, and who contracts for such projects with a
Contractor(S)
licensed pursuant to the Contractor's License Law.
C1 .m exempt under s.p. ,B.aP.c.for this
beson APPLICATION DATE VALUATION PERMI FEE
Owner Dote /�
WORKERS' N COMPENSATIODECLARATION Building
1 hereby affirm that have a ertificate of consent to self insure,or a car
tiliceu of Workers'Compensation Insurance,o e certified copy thereof(Sec. �•
��
3800,Lab.C.). Seismic
/
Policy No. Com puny Total
I7Certified copy is hereby furnished.
Certified copy if filed with the city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' N C O PERMIT AUTHORIZATION DATE
COMPENSATION I NS URANCE
(This{action need not be completed if the permit if for one hundred dol
on;($100)or Ina.)
I certify that in she performance of the work for which this permit is
issued, I {hall not employ any parson in any manner so as to become subject
SfRzi
fes the rke 'Compensation Laws o1 California.
Dab l Applicant
NOTIC T APPLICANT: If, after making this Certificate of Exemption,
you Should become subject to the Workers' Compensation provisions Of the
Labor Code,you must forthwith comply with such provisions or this permit
Snell be deemed evoked. All roes hall be Inspected prior toany roofing material being
I certify that 1 have read this application and state that the above informs InstalledI If a roof Is Installed without first obtaining an
tion I. .p act. I agree to comly with all city iy end county ordinances and Ins ectiorh,I a ree to remove all new materielsforins action
+tate lawla
reting to building construction, and hereby um.fl,. repra+en / p g p
tell...of this city to anter.,on the above mentioned property for impection /
purPo{...
we) I/
e) agree to save, indemnify and keep harmless the City of Cupertino i
o
.g.in.f liabilities,judgments,costs and..Pam..which may in any we, accrue '-
.wino +aid City In consequence of the granting of this armit. SIG R O LI A 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