R-4135 (2) PERMIT
APPLICATION FOR - CITY OF CUPERTINO NUMBER R- 4135
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 OT
YITHIN IN DAYS OF PT EXPIRES IFDRK RM TIS�SUAN ETOR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS I /t�, BUILDING USE
LS I Z � LI y I �e�_ 4 "`� RESIDENTIAL COMMERCIAL OTHER
OWN ^ l
E 1�� C�Y�-- HAZARDOUS ROOF
NAM
r FIRE COVERING
AREA CLASS
ADDRESS Z 1 CCGu n J-Q SQ V ) L I'li EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S -
U TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
CIDTDY&ZIP I0TZ_ �l I.,/ ire 51 951z
q EXISTING
PHONE !�-.� —9,4 , � BUILT-UP ROOF
LICENSES / �� —1 ASPHALT SHINGLES
NUMBER l7
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(<ommen-
ing with Section TOM) of Division 3 of the Business and Professions Coda, WOOD SHINGLES
and
my liana ie In full Tome and affect. �j �+1y7I�p�.�
License Clan Lic.Numb. OTHER (SPECIFY)
OOVtfER"BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the following noon. (Sac. 7031.5, Business and Profession*Code: Any city
Or county which requires a permit to construct, alter,Improve,demolish,or
spa any structure,prior to its issuance,also requires the applicant for such BUILT-UP ROOF
permit to fila a signed statement that he r,licensed pursuant to the provisions
of the Contractors License Law (Chapter 9 (commencing with Section 7000)
fromDivision 3 0l the Business and Professions Dodo)or that of n exempt[hese' ASPHALT SHINGLES
of D and the breis for ess allegro exemption.od Any violation of Section
7031.5 by any applicant for a permitubjects the applicant to a civil penalty
of not more that five hundred dollar,(9somd: WOOD SHAKES
❑ I,ss Owner Ot [he property, Or my emplOyaet with wage.ee their tole
compensation,will do the work, and the structure is not intended o offered
for sols(S«. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
Law does not apply to an owner of property who builds or improves thereon,
and who does such work himself or through hes Own smplOyeas,provided that
such irrlprovarnenli are not intended or
offered for sale. u, however. the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
build., will have the burden OI proving that he did not build or improve for
Purposeof sale.). PROVIDE I.C.B.O. REPORT NO.
C] I.
as owner of the property. am exclusively contracting with licensed
contractors to construct the project (S.C. 7044, Business and Profestla
on
Code: TheContr«tors License Law does not apply to an owner of Property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves [hereun, and who contracts for such projects with If
contractor($)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under sec. ,B.aP.c.for this APPLICATION DATE VALUATION PERMIT FEE
Owner Data I ® 6
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I have a certificate f consent to sell insure,or a car . ' F
of iced of Worker,'Compensation� lnsurad
copy
thereof(Sac. ��� Y" _ BISmiC
3300,La .1. U (J [�`
'POI*Ci,ic. Nog F7 EPA., .J-�l"` ;7r—L,"
19 J O
Cert tied c pv is h.r.by furnished. Total
Certified copy is filed with the city inspection division.
Applicant !� u - r
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.ElPERMITAU HI A AI UN - DATE
COMPENSATION I N S URANCE
(This saction need not be completed if the permit is for One hundred dOI"
Ian(51010or Ins.)
I certify that in the performance of the work for which Nis permit is 1 A
mad, 1 shell not employ any person in any manner so as to become subject (�"'�'Z"•—tom /4(/
10 the Workers'Compensation Law.of C.Iifomii
DateApplicant
NOTICE TO APPLICANT: If, attar making this Certifiote of Exemption,
you Mould becomes subject to the Workeri Comb ensetion prOvi.i Ons of the
Labor Code, you must forthwith comply with such provisions or this permit All roofsshall barns inspected prior fOOiln material been
.hare be Claimed revoked. P P Y 9 g
I certify Nn I have read this application and state that the above informs Stalled. If a foot s Installed without first obtaining an
tion is coria t. I .qr.. w comply with .11 city .tad county ordinances f Ina e N p I a re to emoveall new materials for inspection.
ante laws relating to building construction, • d hereby authorize represent P •� g P
purpo of this city to mar upon the above mentioned property for inspection
pw )
(We)
IW 1 egrea s, uva, indemnify and kap harmless the City o1 COO ItIPO
against liabilities, cons judgments,corn and expenses which they in my wry acme DATE
against said City In consequence of the granting of this parmiv N URE OF APPLICANT
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