R-4129 APPLICATION FOR PERMIT R- 4129
CITY OF CUPERTINO NUMBER
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
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
q2_ vl RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
,A r �
NAME I N Z , '1��Q- nQVIiI 1% �G FCOVERING
CS ING
ADDRESS w
�o( e!'A- !! \J ' -SA-.-SA-. (ISTING ROOFCOVERING
PHONE GW) +/ — JO 3'S NUMBER OF EXISTING COVERINGS /
CONTRACTO 'S 1 TO BE REMOVED / TO BE RETAINED
NAME �V l d r �Or� C evHp�. �l TYPE OF ROOF COVERING
CITY&ZIP l$ �3 S -7+11 ( EXISTING �/
PHONE 171 - 2SOO BUILT-UP ROOF X
LICENSE it T CJ ZQ 'O ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I nosey affirm thst I of ivi.grd under provision of Chapter s(commde,
anp with swoon a000l ase Diyi.ml 3 or m. Burins. a P.o+es.mn.case.. WOOD SHINGLES
and my licenf i•y rKy® fee affect.
Osu sa Cl ur/)s+�sC... J /,c•• Contractorr '1 �fil y1V J OTHER (SPECIFY)
OWN• ER-BUILDER DECLARATION 1_Y—lam'
1 hereby affirm that I am exempt from the Contractor's Litems Lew for PROPOSED
the loRowiny reason. (Sec. 7031.5, Business and Prot anions Coe.: Any city
.� County which requires a permit to construct,alter, improve, da ri.14h,Or
palr.nr nr➢cerre, prior to its issuance, also requires the applicant for such BUILT-UP ROOF
pomH to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's3ofthe Licend Lew (Chapter . (commencing with Section t7000)
here
from
Division 0 or basis
Business and gedn xem tion, or that he is exempt meld" ASPHALT SHINGLES
from ane the Does for the alleged exemption, Any ant to
of Section
of7031 not o any applicant fore permit subjects one applicant to e civil peneltY
of not 1.as that stye the redpro dollars r my em WOOD SHAKES
❑ I,• owner of ma property,or n. employees with wends as toff role
con it (Sic. will do me work,and the nruCo re is not intended Contractor's offered
for ash (sec. apply tofinao end Profusionswhoa: The orprovsLicense WOOD SHINGLES
Lew does not apply •O an owner of properly who builds to improves Provided
thandat
Such
who don such work not
int or edorthrough offered
owes employees, howiver,met II,,��,,�� 1
such ng ., .mann are not old wild or one
year
1or sale. ti oweveq me OTHER (SPECIFY) YV10�` WA2N
building or improvement is sold proving
ossa veer o+completion, me owner.
op
builder will neva the burden of proving m•[he did not build or improvelor 3! ! 2-
pOr05 o+sown PROVIDE I.C.B.O. REPORT NO.
❑ 1, n to co construct
ma property,Project ( ec.7 44.vely comress a wiles licence
ode: Trs [o consquct icen. seL (sac. x app Business stns and P.properly
Code: Tnsoonvcove's License and does whoco[eppts foeuch projects
c�tswith a PROVIDE MFGR. INSTALLATION SPECS.
who ac fldsor( o mOedypu pursuant
to and who contracts fore La projects wiles a
co EJ I a(s)licensed purser enc n ma Contractor's License Law.
❑ 1 am exempt purer sec. ,Bea Pec m.this APPLICATION DATE VALUATION PERMIT FEE
Owrar Date
WORKERSCOMPENSATION DECLARATION Building
List-
I hereby affirm that 1 have a certificate oi consent to sell-' re or•car pp 111 Qin
hficata of Workers'Compensation Insurec. opyt hereof(Sec. A i D -7 OG' Seismic
3800, No. ilt 1 � V
Policy of
Comoeny
8 Certified co s hereby furnlsPdtl. IUN21 1(�95 Total
Cdrtitie pv +ilea wi M1e ✓pion. , 9
AOOlicent
CE CATE OF EXEMPTION FROM WORKERS' -P AUTHO DATE
COMPENSATION INSURANCE N.C.❑ CI -I V yyt ,
IThis section need not be completed if me permit is for one hundred dol. V
len($100)or I.N.)_
IssuecoHtr m•1 in me performance of ma work for which this permit b
a, I sneH not employ any person in any manner so as ro become subject fill
to the Workeri Compensation Laws of California,n
Den Applic•nl
NOTICE TO APPLICANT: If, offer making this Carbficata of Exemption,
you should become subject to and Workers' Compensation provisions of the
Labor Coda, you must forthwith comply with such provision or this permit
shell be loaned revoked. All roofs shall be inspected prior toany rooting material being
I certify That I have read this application and state that the above informs Installed If a roof is Installed without first obtaining an
tion is correct. I egrn p g p to comply with all ciity and county ordinances and Inspection,I agree to removeall new materialsfor Inspection.
uta laws renting to building construction, d hereby ahthoeita .prasam
fe[ivas of this city to inter upon the above mentioned property for inspection
p Live.o.
(We) agree to save, indemnify and keep harmless the City of Cupertino
again.,liabilities,judgments,cost.and expanses which may in any way accrue
against said City in consequente of the granting of this permit. IGNATURE OF APPLICANT 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