R-3995 PERMIT R• 3995
APPLICATION FOR CITY OF CUPERTINO NUMBER
R—
PERMIT wsPECTION DIVISION PERMIT IFWORK
EXPIRATION
PERMIT EXPIRES I FWORK I NOT STARTED
(408) 252-4505 EXT. 228 WITHIN 160 DAYS OF PERMIT ISSUANCE OR
/ 160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/�—If' BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S �+ I
HAZARDOUS ROOF
NAME COVERING
A CLASS
12
C .�
I , EXISTING ROOF COVERING
PHONE v ' I ^�� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S TO BE REMOVED O TO BE RETAINED
�
NAME��Y YAC 1�� zn TYPE OF ROOF COVERING
ADDRESS
EXISTING
PHONE v 1 VBUILT-UP ROOF
LICENSE ASPHALT SHINGLES \
NUMBER WOOD SHAT X17
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I em licensetlnder provisions of Chapter B(commem
ing with section 9000 pf Dimslon a of the epi ,and Profession%Code, WO SHINGLE
and my Ilcans I f ca end affect. I _
License a Luc'Numb OTHER (SPE I
Data - CECL p
RBUILOER DECLAR 10 ///••////// V
I noaby affirm tna I m exempt from the Convector's Licenee Low i r PROPOSED
the following rpenn, (Sec. 7031.6, Business and Professions Coda: Any city
Or county which requires a permit to construct. alter, Improve,demolifh,or
repair any structure,prior to Its issuance,also require,the applicant for such BUIL R
Permit to fila a signed statement that he is licensed pursuant to the proviso ons
of the Contractor'. License Law (Chapter 9 (commencing with Section 7000)
'
from
Division 3 of the Business th and Professions tion. or[hat he ti endo. S more SPH HINGLES
from end the breis for the alleged exemption. Any ant to
of Section
)031.6 by any ,live ant fore permit subjects the applicant to a civil penalty
of not more[nae Roe the mus(shy em ODD SHAKES
❑ 1,a a11 of me p.o work, and
o he employees with wands as r oil sons
fompmaa[ion,will do the work, Pr or
structure is not intended offanse
for Sala(Sec. apply Boerne„and f Property
who
The Contractors License W OD SH 1 S
Lew does not apply to e lf of property his
buries or improves provided
that
and who does such work himself or through his own employees,provitlee the[
such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building or improvement is fold within one year of completion, the owner
builder will neva the burden of proving that he did not build or improve for
purposeof sale.). PROVIDE I.C.B.O. REPORT NO.
(J I, as Owner OI the property, em exclusively contracting with licensed
connac tors to construct the project (Sec. 7044, Business and Professions
Coda: The Contractor's License Law does not apply tp an Owner of property PROVIDE MFGR. INSTALLATION SPECS.
Who bu iltls o improves mareun, and who contracts for such projects with a
contractor(a)licenced pursuant to the Contractors License Law.
reason APPLICATION
em exempt undo. sec. ,B.aP.c.for this
aPPLICATION DATE VALUATIONPE MIT FEE
Owner Det. /y
WORKERS'COMPENSATION DECLARATION `4 10 BUlldl
ilo
1 nerabV affirm that 1 have rtilicen 1 sant to fall insure, r Car fr_
titian of W ken'Compenf In1ur or ce tifiatl there f(Sec. `(,/yn�, e Seismic
3800,La .1.
Policy No. I I mpet)V /t/f L 19gs , l� Tot �L
BCertified copy is hereby furni,had. 4 (( Grp
Certified Copy is flied with ma city Inspection divi n.
Appli�ant h(, ,} �
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
C ❑ 0", IT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol
bre($100)or In,.)
1 certify ll Met ,n he partgrmence of the work for which toil permit is
issued, IAl ,employ any parson in any manner so o,to become wbjact (`
tq the orker'Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption, '
you should become subject to the Workers' Co,npansetion provisions of the
Labor Codd,you must forthwith comply with such provisions o.this permit All roofs shal(beinspected prior toany roofing material being
shell be ddemetl revoked.
I certify that I have read this application and state that the above informal Installed. If a roof is installed without first obtaining an
`Ion is laws
correct. I dor.e to ng con with n, city and bycounty ori ie r e r and inspection,1 agree topemo a all ne materiels fori spection.
seta laws slating o building construction, d hereby authorize
fora npnsem
purpo rel this tory tq mor upon Me above mentioned pfOperty for InsOaction �_..
we) agree to save, indemnify and keep harmless the City of Cupertino
against liabilities,judgments.costs and expenses which may In any way accrue
against said City in consequence of the granting of this permit. SIGNATURE OF APPLICANT DAT
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