R-41634b
0
OFFICE COPY
PERMIT416
-
R 3
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMIT WIEXPIRES80 DAS OOF F PERMIORK T SUOT AN ARTED ETOR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
r/^GP`y/ ✓G
/C.T
HAZARDOUSROOF
FIREJ
COVERINGNAME AREA X
CLASS
/J
�G'G`1�ry2!/3
EXISTING ROOF COVERING
/s S(��
ADDRESS->2�✓7Z l//,---
NUMBER OF EXISTING COVERINGS
PHONE ,�Z-- (D ya
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME EU G%//� „ /fJl�/l,PjjtOOL/NCo
TYPE OF
ADDRESS
�IGA �2
IITb ✓ 7" %7 .
CITY
EXISTING
f�? 97
BUILT-UP ROOF
PHONE Al
'lir
LICENSE! ��Cy !
ASP LES
NUMBER ! /
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under Provisions of Chapter 9 (common
Ing with Section 7000) of Division 3 of the Business and Professions Code,
WOO LES
and my license is In full force and effect.
License Clan LIT. Number
Data coinactor
OTHER (SPECIFY)
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for
PROPOSED
the following reason. (Sac. 7031.5, Business and Professions Coda: Any city
orcounty which requires a permit to construct, alter, improve, demolish,or
I1 p
P
an
repair any structure, Prior to its issuance, also requires the applict for such
fY I Dp1
BUILT-UP ROOF
Permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractors License Law (Chapter 9 (commencing with Section 7000)
.JVD
of Division 3 of the Business and Professions Code) or that he it exempt there
from and the basis for the alleged exemption. Any violation of Section
A$P GLES n Q ann�
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not mon tn.t five hundred dollars ($500).):
❑ 1. as owner of the Or my employees with their
WOOD SHAKES CI�-i•
Property. wages.. ,plc
Compensation, will do the work, and the structure is not intended or offered
r UrtH I INV
for Isla (Sac. 7000, Business and Professions Code: The Contractor's License
LES
Lew tlon not aPPI y to an owner of property who builds or improves thereon,
and who tlon such work himself or through his own employees, provided that
such improvements are not intended oroffered for sale. U, however, the
OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
°pons owns
PROVIDE I.C.B.O. REPORT NO.
1 s r of the Property, am
44, comress an with licensed
Co tore to construct the project (Sec.
tic. 7 Business neat antl Professions
e:
Coda: The connxm:+ not ofPropertywith
oesuch
and doeswho
PROVIDE MFGR. INSTALLATION SPECS.
con tracts for
wM10 builds or improve hefoue end who for such Protech with s
pr a
contractoram licensed actoracn
pursuant ro the Connector's License Law.
scant t
n
❑ I .m exempt under sacs ,B.aP.c, for his
reason
APPLICATION DATE
VALUATION
PERMIT FEE
Owner Data
WORKERS'COMPENSATIONDECLARATION
I hereby affirm Ino 1 have i certificate of consent to sal Linsu ra, o
tifiub OI Workari Compensation Insurance, o a certified copy thereof (sec.
/// _
y�
�/
y�
(/
(•�
Building
O
Sel$mic 1 �'
3800, Lab. C.).
/
Policy No. Company
8 Certified copy Ie hereby furnished.
TDtal"—�
Cart i tied copy is filed with the city inspection dlvi si on.
Applicant
PERMIT AUTHORIZATION-
DATE
CERTIFICATE OF EXEMPTIONFROM WORKERS' N C 0
COMPENSATION I N S URANCE
(This section need not be completed if the Permit is for one hundred dol
las (f100) or
1 certify loafhat in the performance of the work for which this Perms[ is
issued, I shall not employ any parson in any manner +o as t0 become subject
to the Workers Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you should become subject to the Workers' Compensation provisions of the
Labor Coda, you must forthwith comply with .uch provisions or this permit
All roofs shall be Inspected prior to any roofing material being
shell be deemed revoked.
I certify met I have reed this application and stela that the above informs
Installed If a roof is installed without first obtaining an
tion is correct. I .grit to comply with all city and county ordinance+ and
Inspection, I agree to remov all new materials for inspection
note laws ofing to building construction, and hereby authorize reprnem
nGvn of this city to anter upon ma above-mentioned property for inspection
r
Purpose..
(W0 agree to save, indemnify and keep harmless the City of Cupertino
f
again I liabilities, judgments, costs and expenses which may in any way accrue
IGNATURE OF fyPLICAyr DAT
against said City in consequence of the granting of this permit.
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
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