R 4081 PERMIT 4081
APPLICATION FOR CITY OF CUPERTINO NUMBERRn
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228
PER EXPIRES IF WORK IS NOT STARTED
WITNIN190 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
MEW BUILDING ADDRESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
� On --- HAZARDOUS ROOF
NAME �Qi✓�� FIRE COVERING
AREA CLASS
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED----L_ TO BE RETAINED
NAME / /`�J9 �,¢ TYPE OF ROOF COVERING
ADDRESS
/�Ll�M //'//�f�� i a., atm V EXISTING
PH0NE4:TTO JcS-y' 45 /0 $/ 0 BUILT-UP ROOF
LICENSE ! "1
NUMBER ASPHALT SHINGLES
Co d
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION '
Y hereby affirm that I am licensed under pmvislon.o1 Chapter 9(cpmmem WOOD SHINGLES
cin with Section 7000) of DiviliOn 0 of the Bu{inn{and Profession.Code,
and my Ilceme le 1 f 1 ce and effect.
Licence _ LIc.Numbn G 4.6-6 AOTHER (SPECIFY)
Date Contractor
OWNER-BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractor's License Lew for PROPOSED
the following anon. IS... 7001.8, Butlnns and Professions Code: Any city
or county which requiring a permit to construct, alter. Improve, demolish,or tom '
repair.rev aructurs,Prior to In Issuance,ats. require.the applicant for such BUILT-UP ROOF
permit to file a signed statement the,he b licensed pursuant to the provisions \'
of the Contractor i Liceme Law (Chapter 9 (commencing with Section 7000) \
oI Division 0 of the Business the
and alleged
exemption.
tion. or that he b exempt Mere' ASPHALT SHINGLES V
hom end the anis for the apermi exemption. Any violation of Section
7031.6 by any ,five hu fora permit subjects the applicant m•civil penalty
Of not more the[live the Pftl doll.OrtV. IS5y OM WOOD SHAKES
I,ti owner of the property. or h. employee.with wends of Meir eyed
compensation,(Sec.
will do the work, and the structure is not intended ',offered
row tele(Sao. ]044, to neo and Professions who
The Con[raove s License WOOD SHINGLES
Law don not apply t0 an owner of property his
builds to des, oras thereon,
and uc who roe enM1 work himself or through his own r saloyan, however,
that
such Improvements are not old wed or n. year d
for sale. It, , thew, tee OTHER (SPECIFY)
building or impr t e bur Is sold proving
one year pi completion, p owner
builder will have the burden of proving Mu he tlitl not build or improve for
Purpose Of sale.) PROVIDE I.C.B.O. REPORT NO.
O I, as owner of the property, em exclusively contracting with licensed
contractors to connruct the project (Sec. 7044, Business and Profusions
Code: The Contractor's License Law do.,no,apply to an owner of property PROVIDEMFGR. INSTALLATIONSPECS.
who builds or improves thareun, and Who contracts for Such Projects with Is
contrntorl0 licensed pursuant to the Contractors License Law.
C3
1 am exempt under Sec. ,S.d P.C,for this
atamn
owner Den APPLICATION DATE VALUATION PERMIT FEE
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm In., 1 neve a certificate of consent to sell insure,or e car. _
tifice[a of Workers',Ceo�mpenntionInw.ence/, certified copy thereof(/Sac. �9 �S ,OD r� Seismic
Poll Lea. C� 5Cjd pin-,
Poll N:r ✓C
C tided cony a ate. by b ed. Total
Certitiad gaQy witM1r city JPNti�. yyEp1
Applicant a 4�l x[—di
CE RTI FIC TE OF EXEMPTION FROM WORKERS' N.C. ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This($ 0 )or On nastl not be cpmp eted it the permit is IOI one hundred dol. f
late IS100f that l
1 certify ha that in Me pa y person
o1 the work for Which co permit it
gamed, I Snell not employ any Person in any manner so as to batpm•Subject
to the Workers'Compensation Laws o1 California.
Deb NT:App (API
NOTICE e, APPLICANT: If, after making thisposoCertificate of Exemption,
You Mould become subject to ata Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or trap permit All roofa shell heins acted prior roofing materialbein
Mau be domed r..ked. P P Y g g
Icertify that 1 have read this application and nate that the above Informs Installed. If a roof is Installed without first obtaining an
tion Is correct. I agree to comply with all city and county ordinance.and inspection,l8 vee to remove all new materials form,, aCtIOR
state laws relating to building construction, and hereby authorise represent g
bores of this city to enter upon the above mentioned Property for Inspection /J J Qs,}�/ 1
purposes. --- — H`w� ^���
(We) agree to gave, indemnify end keep harming the City of Cupertino /1 x
ageing laid City
i judgments,s secosts and expenses f this erY In any way accrue
1 against teid City in consequence of Me granting of Mb Permit. SIGNATURWOF 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