R-4005 PERMIT R_ 4005
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION r PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WOT STARTED
WITHIN 180 DAYS OF ERM TORK IS ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
86 ?= _
0. I D RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME f'r\ C,se Yh r5 5 D Ce—i FIRE COVERING
//�� 11 AREA CLASS
ADDRESS,/—`-7 T 6 tF Y0.f� n �S Pb6'� EXISTING ROOF COVERING
PHONE
5��. 6 S 3 1 NUMBER OF EXISTING COVERINGS
I1
CONTRACTOR'S
FN W+^0.k s S a'✓1 G TO BE REMOVED TO BE RETAINED
NAME Clfl ^P TYPE OF ROOF COVERING
ADDRESS 9,),�/-+q2 L fin G.okn "W EXISTING
PHONE $ 5 5- 6 q7 BUILT-UP ROOF
LICENSE SS 3� ASPHALT SHINGL
NUMBER
WOOD SHA
LICENSED the,;a CONTRACTORS DECLARATION
hereby ctor,affirm
mat 1 of ivi.i.tl of t provisions of Chapter
..(comment
ing with s«tion)000) of Divi%ion 3 of the Business ears P•oLnlOo Code, WOO SHINGLES
and my license b 1 II force and eff.t.
oleo.e sees 14j uc.Number S--la�°w�1 0TH (SPECIFY( ^
fEL=�JL,3 Contractor K_
OWNER BUILDER DECLARATION ✓L
I nearby affirm that I am exempt from the Contractor'. License Lew for PROPOSE \
Me following res on. (SK. 7031.5, Business and Professions Code: Any city
or county which requires a permit to construct, alter, improve, demolish,or ^
repel/any structure,prior tom issuance,else require.the applicant for such BUILT-UP OOF
permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor'. License Lew (Chapter 9 (commencing with Section 7000)
' of Division 3 of the Business and Professions Coda)or that are is exempt mere ASPHALT S NGLES
from and
the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a Civil penalty
of not more mat five hundred dollars( 50OH: WOOD SHAKE
❑ I,as owner of the property,or my employee{with wage{as their site
compensation, will tele do the work,and the structure is not intended or offered WOOD SHINGLE
for le(Sec. 7044, Business and Professions Code: The Contractor's License
Law don not apply t0 an owner of property who build{or improves thereon,
and who does such work himself Or through his own employees,provided that
such improvements are not intended or offered for sale. If, however, ,n. 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
pu,pos..f safe.). PROVIDE I.C.B.O. REPORT NO.
[31, s owner of the property, am exclusively contracting with licensed
contractors to c nstruct the project (Sec. 7044, Business and Professions
Code: TheComo«Inr'sLicense Lew does not apply to an owner of Property PROVIDE MFGR. INSTALLATION SPECS.
who builtl% of improves thereon.and who Contract{ for such project{with a
conbKtor(s)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. ,B.&P.C.to•this
lesson APPLICATION DATE VALUATION PERMIT FEE
own.,---- Date
WORKERS'COMPENSATION DECLARATION Building
1 hereby affirm that 1 have a certificate of consent to self insure,or a car. //``q
oficate of Workari Compensation Insurance,or a certified copy meraof(Sec. L X33 Seismic
3800,Lob C.I. .s2 arL -`� /�� 9 S V
Policy No. i0G �Q ompany O\{JY MV is
8 Certified copy is hereby furnished. Total
Certified copy is filed with&cityection division,
Applicant �l
CERTIFICATE OF EXEMPTION FROM WORKERS' N L, PERMIT AUF'H R ION DATE
COMPENSATION NEURANCE v
(This section need not be completed it the permit is for one hundred dol.
Isar DDI Or I ]995
1 certify that in the performance of the work for which this permit is -
ed,d, I shell not
O[employ my person any manner{O M to become subject APR 3
to V Work.,.Compensation Laws of Q�'enfornie.
Date Applicant_spy �,'�
NOT
TO (CANT: If, .Inr eking this tifiute of Exemption, V Uf•
you should b«oma subject to the Workers'Compensation provisions of me GUrEH11NU
L.bor Code, you must forthwith comply with such provisions or this permit All roofsshall be inspected priortoany roofing material being
.hell be deemed revoked.
I cntlty that I nay.rend this appliaatiorn and If.,. he, he so..informs installed If a roof Is Installed without first obtaining an
tlon is correct. 1 agree to comply with all City and county ordinances and inspection,Ia agree to remove all materials for action
stn. laws relating to building construction, d hereby autnorits .Pr..n. P n, 9 P
ro of nth city to Amer upon the above property inspection
pup
(We) agree 1.s. wee, indemnify and keep es which
the City of CUPS
c no lb—rCE/� r,•N`
against said
City i judgments.cess and expenses which may in any wry Kcroe
ealoss aria city m=onoauan=e of me pooling of this Permit. SIGNATURE OF AP'PLICANT 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