R 3989 PERMIT 3 9 8 9
APPLICATION FOR CITY OF CUPERTINO NUMBER R�
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IN DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ��,� �/"� �//' BUILDING USE l 1 9_.N F(/V n V R�ENTIALy_L_ COMMERCIAL OTHER
O R 1
O HAZARDOUS ROOF
NAM O'Yl r FIRE COVERING
AREA CLASS
ADDRESS EXISTING ROOF COVERING
PHONE f • l NUMBER OF EXISTING COVERINGS I
CONTR O S \J(
/DIY's TO BE REMOVED TO BE RETAINED
NAM �1'0�,�' 1 n ,, TYPE OF ROOF COVERING
R ESS
CTDY ai ZIO -I_ W t ISTING
T'
PHONE -A15 LA q3 BUILT-UP ROOF
LICENSE2_2ASPHALT SHINGLES
NUMBER L4 ig
CD WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em Ilcansetl under provisions of Chapter 9 Icommem
cloy with Sac n 7 o iwsion 0 of Ma Buell t.t�ertdv on oda, WOOD SHINGLES
and my Ilan sin iW rca d affect. ` Cy�J(
Llu s Lic.Num
Data Contract , OTHER (SPECIFY)
bWQR-BUILDER DECLA I N
I hay.by affirm that I em exempt from the Contractor's License Law for PROPOSED
the following repan. (Sec. 70]1.8, B "nese ane Profan10 de: Ain city
or county which requires a permit to constrvct, alter, imp, tleITT I's or
repair any structure,prior to ib Imance,8,110 re4uirp the op M'lo,such BUILT-UP ROOF
Perm
it to file a signed statement that he 1111c.. esu rwant to pr vilians
of the Co ITsl 3 of s Business
Law (Chapter s (commend wi S 000)
of in'andn 0 0l Ma Bfar In antl Proflood
.. m tion. or the • e e ASPHALT SHINGLES
from and the apps for far allayed examOtion./An v to Section
70not by any t five hu fora permit snbjact� • li n civil p , .
of not more that stye hundred amLrs ISBooI. WOOD SHAKES '`� p 0 t�
❑ I,as owner of the property,or my nruplOy as ;Wages as their sole
compensation,will do the work, end the Et I. 1 intended or offered Vy00D SH INGL
for$ le(Sec. 7044, Business antl Profelli The Connector s License /1(l, f.
Lew sop not eDpIV to an owner of D oyper o builds or improves thereon, VAN J /^^
and who doer such work himself or th rOL eel sen emglci provided that _ 6
such improvements are not intended o 1,p f led for sea. If, however, the V
building or improvement is sola within one year of completion, the owner. OTHER (SPEC(FfYUf
builder will nava the burden of proving that he did not build or improve for �Ur:HitH/�
purposedl aale.l. .0
❑ I, a1 owner of the Property, am exclusively contracting with licensed PROVIDE I.C.B.O. REPORT NO.
contractors to construct the project (Sec. 7044, Business and Profession.
Code. The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who Contra",for such projects with e
c Pntractorla)licensed pursuant to the Contractor'.License Law.
Cl I am exempt under Sec. ,B.&P.C.far this
res
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKERS'COMPENSATION DECLARATION lashd�
I Building
I
hereby affirm that I neve a certificate of an t to ul6in e,or a c re I 38001 of or n'Cotnygpa ryl/Vurence, c stifle ereoi IS c O D� elsmiC
0800La 1 17171 CCJJ�� ((��dd,11VVJJ_
P Ilcy N:. o en
�11-C ti DY snore lu than tl.
O Cat fi c p i1 d rtpi ' v . c ' news ion. Total
Applicant A
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
This lection need not be completed if the permit is for one hundred dol
Ian 131001 or Ian.l v
1 . I aha that m the performance person
of the work for which this permit i.
ex
Inued, I shell not ampbY any person in any manner m a1 to become sublet[
to the Workers'Compensation Laws of California.
Ops Applicant
NOTICE should
APPLICANT: o after making this nst ion n of Exemption,
You r Cod become me tsubject i me Workmply w h such provisions
Finnsov this a tlrmit
Labor Code, You mutt lorthwim comply with such provlsiom or mil permit All roofs shell be inspected shall be doomed revoked. p cted prlortoany roofing material being
1 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 agree to comply with all city and county ordinances and Inspection 18 agree t0 reMo all new materlalafor Inspection,
state laws relating to building construction, and hereby authorize reprpem p g p ction,
[shyer of this city to enter upon the above mentioned PrOPotY for inspection �� i I��
purpose..
nvdsOf
(we) agree to says, indemnity and keep harmless the City of Cupertino
against liabilities,judgments,coats and expenses Which mese In any way accrue
against said City In consequence of me granting of this permit. SIGNATURE 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