R-3961 (2)APPLICATION FOR
REROOF PERMIT
OWNER'S G
NAME // 57/ a1;2 /�li
5/o S% q
PHONE 7�0_. }p/,nC
5
CONTRACTOR'S
NAME FVJ 15d,:h7S
ADDRESS
CITY & ZIP I
San Tose
PHONE T'/DK
CITY OF CUPERTINO
INSPECTION DIVISION
(408) 252-4505 EXT. 228
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed ..it., p,.vW... o1 Chapter 9 (commam
ing with Section 7000) of Division 3 01 the BusUess a d Profassio oda,
and my Ci eme b IA fu W ep�r and effect -�
Lica me Cfeu L. � �/ t Number
bets Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
or county which requires a permit to construct, altar, improve, demclisll
repair any structure, prior to its issuance, also requires the applicant for such
permit to file a signed statement that he Is licensed pursuant to the provision
of thContractor's License LAW (Chapter 9 (commencing wiNS.c Oen )
o1 Division 3 of the Business and Professions Coda) or that he is exe hi
from and the basis for the alleged exemption. Any violet of sacti n
7031.5 by any applicant for a permit subjects the applies o a civil penal
of not mon that five hundred dollen (95001.):
O 1, as owner of the property, or my employees iN wages r I
ccm pentatlon, will do the work, and the structure i not intended e
for sale (Sac. 7044, Business and Professions Code' The Contractor r u
Lew does not apply to an owner of property who ullds or impr t coon,
and who does such work himself or through his o n e lo,ee ee in
such improvement. are not intended or offers for s 1 r j}a
building or impr ovemam is sold within one ye of co b n, the
build., will have the burden of proving that he not
purpose 01,jQfypJSj1�
] 1, N OwMr OI Na PrgPertY. a rt usiyet, ntract in f. used
contra to construct the project (Sea 7044, B ess n W Pr
Code: The Contractor's License Law does not apply t n ow r of or rty
who build$ or improves thereon, and who contacts for h pr s with a
contractor($) licensed pursuant to the Contractor's License Law.
0 1 am exempt under Sec. ,B.&P.C. for this
reason
OwnerDate
WORKERS'COMPENSATION DECLARATION
I hereby affirm that 1 have a certificate o1 consent to salt insure, o
otic.". of Workers' Compensation Insurance, ora <e [ified copy thereof (Sac.
3800, Lab.�LfI.�������q.���scc__ �t /��
Policy NO.(�JCcmTp.nv SEAT / Q�il n
jCertified cop, d d hereby furnished.IS
Certified copy is filed with the city inspection division. -
plicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION I N S URANCE N.C.
(This $action need not be completed if the permit is for one hundred do1�
lets (S100) or I...)
1 certify that in the performance of The work for which this permit is
issued, I shall not employ any person in any manner so as to become subject
to the WorkerWork.,.'Compensation Laws of California.
Oat. Applicant
NOTICE TO APPLICANT: If, aft., making this Certificate o1 Exemption,
you should become subject is the Workers'Compensation provisions of the
Labor Code. you must forthwith comply with such Provisions or this permit
shall be deemed revoked.
1 certify that 1 have rand this application and state Net the above informs
tion I$ correct. I agree to comply with all City and county ordinances and
.Leta laws relating to building construction, and hereby truth o rise represent
Utives of this city to enter upon the above-mentioned property for inspection
purposes.
(We) l to Save, indemnify and keep harmless the City of Cupertino
against liabilities, judgments, cons and expenses which may in any way accrue
against said City In consequence of the granting of this Permit.
PRE-INSPE
INSP.
TEAR OFF I
INSP.
PERMIT
NUMBER R- 3961
PERMIT EXPIRATION
PERMIT E%FIRES IF WORN IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
OTHER
ROOF
COVERING
CLASS _
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
TO BE RETAI
EXISTING
BUILT-UP ROOF
ASPHALT SHINGLES
WOOD SHAKES iC
WOOD SHINGLES
OTHER (SPECIFY) P A I D
PROPOSED MAR 16 1995
BUILT-UP R6017 UJ- j Ut EHI '
ASPHALT SHINGLES
OODSHAKES
W OD SHINGLES
THER (SPECIFY) L.,Omw0ca
PROVIDE I.C.B.O. REPORT NO. 1312 -
PROVIDE
2.PROVIDE MFGR. INSTALLATION SPECS. /0 SAA
'LIGATION DATE EVALUATION
Ing
All roofs shall be inspected prior to any roofing material being
Installed If a roof is Installed without first obtaining an
Inspectlo tee to remove all new materials for inspection
SIGNATURE OF APPLICANT `� DATE
PLYWOOD: IN -PROGRESS:
DATE INSP. DATE INSP. DATE
ON: BATTENS: FINAL:
DATE INSP. DATE INSP. DATE_
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY