R 3988 [�NUILIIMBERRSISERMIT
APPLICATION FOR CITY of CUPERTINo 3988
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT.228 WITHIN 180 DAYS OF PERM T ISSUAN ETOR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING (A`—D7�DREESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME FIRE COVERING
AREA CLASS
A Dp RESS
EXISTING ROOF COVERING
p
I`^Ar-� gl .. NUMBER OF EXISTING COVERINGS
PHONE
CONTRA OR'S
^^ TO BE REMOVED TO BE RETAINED
NAME ]-I" r 1 TYPE OF ROOF COVERING
CDDRI Zlb I �D EXISTING
PHONE '� \ � " tiJ�(�� BUILT-UP ROOF
LICENSE �Z � ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS undo, DECLARATION
I with S affirm that 1 em licensed under prov6ions of Chapter (common
Ci.g with s«si 0) oim,lon 3 or the 0ud9e.4 mp.Rrp{q,.�one cos., WOOD SHINGLES
and my Ile n. s n f •ens:fn
l�J
DoLit, u Lic.Nu /' OTHER (SPECIM
Dose cont, or
ER BUILDER DEC
I nae y of rm that I am a.empt 110.the Cpntnmor i LI—no. Lew for PROPOSED ��
the following resod.. (Sec. 7031.8, Business and Professions Code. Any city /4
or county which .quires a permit to construct,slag Improve, demolish,oI
.Pah any structure,prior to Its Issuance, also requires the applicant for such BUILT-UP ROOF
permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew (Chapter 9 (commencing with Section 7000)
o Division 3 of me Business end Code)or that he is exempt main
from
ASPHALT SHINGLES
Iron ens rite bels for the alleged
exemption.
ption. Any violation of Section
7031.8 by any applicant for a permit subjects the applicant to a civil penalty
of not more that five hundred dollars 1$500).): WOOD SHAKES
Ej I, as owner of me property,or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered
for•ale(Sec. 7044, Business and Professions Code: The Contractors License WOOD SHINGLES
Lew dam not apply to an owner of property who build&or improves thereon,
and who does such work himself or through his own employees,Provided that
such improvement, are not intended or offered for sale. H, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the o
builder will have the burden of proving that he did not build or improve for
pu,poes chi sale.). PROVIDE I.C.B.O. REPORT NO.
I, s owner of the property, am exclusively convecting with licensed
convac ton to construct the project (Sec. 7044, Business and Professions
Code: TheCuntraclor'sLicense Law does not apply toanowner ofproperty pROVIDEMFGR. INSTALLATIONSPECS.
Who builds or improves theroun, and who contracts for such Drolacn with a
contrector(s)licensed pursuant to the Contractor's License Law.
an am exams[ under Sac. ,B.&P.C.for this
,.. APPLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION to ON ,{, Building
I hereby affirm me[ 1 have er .'It.
o.,ae f consent to lc;,nraw r r e c ; 1 1
tificaq�l.lyo ker Com �uqp� Insunn o certified copy to re S c .LI t .-1y( �'�— Sei9mIC
390OV Q.I (/I �m�YA
Polic]y C l li �u r
I7G led copy is thereby les ed. Total
C r1i i is i ion tliviuo
APpllcan
CERTIFICATE OF EXEMPTION F M W RKERS' N.C.
D 0 PERMIT AUTHORIZATION DATE
COMPENSATION INSUR NCE
(This section need not be completed if the permit is for one hundred dols I�
Ian(5100)or that
i
1 certify at n me performance of the work for which this permit is
lssuad. I shell not employ any person In any manner so as to become subject
to the Workers'Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate or Exemption,
You should,become subject to the Workers' Compensation provbiom of the
Labor Code,you must forthwith comply with such provision or this permit All roofsahell be inspected rlOrt08n roofing meterlalbeln
,hall be deemed revoked, P P Y 9 g
I certify mat I have read this application and state that the above inform. Installed If a roof Is installed without first obtaining an
tion is emree I ogres to ng cons with all city and county ordinance and inspectlo'r.(-erg[@e to re OVaallo aterIsforl rL
tattate law, elating to nter no theabove end ned Pr authorise rspction p
purposes,al this city to,ter upon the above mentioned Property for inspection
purposes.
(We)l agree s, sew, en ts,Ole and keep harmless the City of Cu actino
against liabilities, consequence
cest,and expeneg which may In my way accrue
again.hila City In coneequan[a of me grentinp df 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