R-4408 (2) i
~ PERMIT R- 4408
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING,ADDRESS L [� (/�•� I /� ,/ BUILDING USE
X0652 '067 �Ty�94 �-1-r RESIDENTIALs COMMERCIAL OTHER
OWNER'S
FIRE COVER
NAME HAZARDOUS ROOF
4 A AREA CLASS ING
ADDRESS I S� l ` i3 toK N�• S U, EXISTING ROOF COVERING) L
NUMBER OF EXISTING COVERINGS / 51L4k�
PHONE
CONTRACTOR'S
CoK�9 TO BE REMOVED TO BE RETAINED
NAME d �0��'�S TYPE OF ROOF COVERING
ADD �g3Lt2 / `t"` AVTl Q �5f1Z EXISTING
PHONE /7 BUILT-UP ROOF
LICENSE 2/IYj�Z ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS under DECLARATION
I withhereS ction 00 I of licensee um-Provisions of d apterProle s(coons Code,
crop y li section T000l of Droisiltn 3 of the enmm and Professions coag, WOOD SHINGLES
and my Ilan,.if in 11 and affect.
License Cep — • Lic.Number
Date - - Contractor OTHER (SPECIFY)
OWNER m eximDER DECLARATION �y
omen yeas that I . sump[ IrOm the Contractor's Code:
Lew for PROPOSEDollow `!moi`✓,(\,
tr ount,inn malty. Iresc. permit, Businesscconstruct,
and Professions i pr Code: Any city
or C1r my which re,Priorres . permit [O e.also re altar,employe, eemolif such repair any file
a signed
prior to its enhance,ciao requires the applicant for such BUILT-UP ROOF
Permit to lila a sinned rtnement mat he is liceom pursuant it the tion 7 00)
of[h•Cont3.0f the LiceBusiness
Lew (Cliental 8 Ino e)or that with Section here
Of
Division 3 of m.efor th and alleged
exemption.
Coal or that he is exempt S[here- ASPHALT SHINGLES
from an e aha anis far the alleged .xampts the
Any violation eoi penalty
TOTS by any applicant hu fore palmi[subjects the epplicent to e civil penalty
or not masa that five hundred tlouen(pS001.): WOOD SHAKES
❑ I, as owner of the property, o he .mployap with wends n their fold
compensation will m ma work, and the structure is not contract 's License
WOOD SHINGLES
IF'
uta Ip ac. apply
to neo and Pr Property Dotla: The Contractor's thereon,Lew eon res apply [o an Owner r properly is o builds to improves Provided
that
and who eon such work himselfint or intended
offered tis own employees,provided iliac
rah ng .,I improv ars not intimae o neya for cola. n, nrthema owner OTHER (SPECIFY)
buil Jing or improvement is sole roving
tont year of completion,or the
burp.. will have me burden of proving ton he tlitl not burp or improvefor
purpltaao spown. PROVIDE I.C.B.O. REPORT NO.
❑ 1, es owner of the he projeerty.ct
t ( ec. 7exclusively4, Busconiness
n with licensed
.� cont.: The to construct she project (pec. tap Bto nap ane Professions pr rty
Code: The Convector's eosin,Lew doeswho notapplyfo.ncw ofpropertywith PROVIDE MFGR. INSTALLATION SPECS.
who brilea or improver scant t and ont Contracts fore La projects with a
conl.ecl am .stat pursuant ro the Contractor's License Law, Ve
r..❑n em exempt under Sea ,B.b P.C.for this
owns Data PPLICAATION'BAT_ VALUATION PERMIT FEE
WORKERS'COMPENSATION DECLARATION IJ? Buildin
I hereby elfirm that 1 have a carti+icate of consent 10 a•R Insure,or a car V
titit.b Of Worker compensation Insurance,ore certified copy thereof(Sac. 1 t//� e
3800.Lab.0.102 97 5,�.� `�". 1 Cl/y(J/;L_ . Q 7T0 Seisms
Policy N., Company (r'p•L4 �%rEkr� O / Total
8 Certified copy' MrepY furnianed.
Certified yp0 iytjl•d wit h:niav'nsp•n ion division.
Applicant %�'�—
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMI AUTHORIZATION DATE
COMPENSATION INSURANCE N.C. 0
(This section need not be completed if the permit is for one hundred dol O
bra(81001 or less.)
I certify Ihn in me performance of the work for which this permit if
issued, I shall not employ any parson any manner so as to become subject
to the Workers Compensation Law,of California,
Det. Applicant
NOTICE TO APPLICANT: If, e...r mek inn this Cer[i+icata of ExemptioP,
you should bacOe msubject to the Workers'Compensation Provisions of the
Labor Code,You mast forthwith comply with such provisions or this permit
shelf be planned!ravok.d. All roofs shall be inspected prior toany roofing material being
1 certify that I have read this application and nap that the above inform. Installed If a roof is Installed without first obtaining an
tion If correct. I agree to comply with au deity and county ordinances and inspection, agree to remove all new materials for inspection.
state law, relating to building construction, a n.reby f. h.rit. wDrpem
talivo of this cI1V[o mer upon SM above-mentioned property for impaction
Pu IPOeep. 2-//-9-
(We)
/`Q`
(We) eon. to love, indemnify and keep hermlap he City of Cupertino ] /
against liabilities,judgments,costs and expenses Which may in any weY accrue
sgaim, aid City in consequence of the granting of this permit SIGNATURE OF APPLICANT DATE
PRE-1 NSPECTION: PLYWOOD: I N-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