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R-4058 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4058 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408) 252-4505 EXT. 228 PERMIT I EXPIRES P STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION BUILDING ADDRESS BUILDING USE IRESIDENTIAL COMMERCIAL OTHER OWNER' ,—, /^/1,X— HAZARDOUS ROOF NAME MCI e l r/ lU✓C.. FIRE �� COVERING /�V�' AREA CLASS ADDRESScy—el©70 y/�(�,grf��fde�y EXISTING ROOF COVERING PHONE -7,3 �7—/7 6 NUMBER OF EXISTING COVERINGS CONTRACTO 0 �� TO BE REMOVED TO BE RETAINED Ste, NAME I\IG !C/ �'IG G / TYPE OF ROOF COVERING ADD azih 0:7 rc Gwl L11 EXISTING PHONE16.4 - 3 ) 4 ;� BUILT-UP ROOF LICENSE Ol"' ASPHALT SHINGLES NUMBER tL�-1 J WOOD SHAKES LICENSED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provisions of Chapter 9(commons cin9 with Section 7000) of Division 3 of the Business and Profession,Code, Code, WOOD SHINGLES and my license if In+ e an d effect Z� License Cl yf Lic.NUmba C� OTHER ISPECIFYI Ea.� Data CC Com;r or l[ _ �'f�F�L�•�' OWNER BUILDER DECLARAT ON l 1 hereby.ream that . exempt brim the d Contractor's Code Any City PROPOSED the following rotors t I a 7031 S. from t end retract ens Coda Any city 1� re air my Which requires a Pas issuance,to construct,requires heappe,ant for such ` recur any structure,d prior statement m en rshat h ei also sad par fha tool went for such BUI LT•UP HOOF rr' permit m his a signed ease Law that na I.licensed pursuant to Se Lion provisions \ 01 the son 3 of the Business Lew (Chapter fessio s (commencing a is Section 7000) from m and 3 of me afar the and alleged exem tiodal or that oa if n of S more ASPHALT SHINGII�f � • berm and any basis fha apermi exemption.the Any violation of Section 7031.5 by any applicant five bu ter a oarmrt wOpcU ms eooh<en[to a evil Penalty a+ ulnas that five hundred dollars(S500) my employees j. WOOD SHAKES I,ti Ownµr of ire pw0ork.a Or he is with wens as Choir tole for sea (Sec. N do fha ork,and she ens Co re not ,otnead Contractor's icerM WOOD SHINGLES ^ for sale (Sec. 7044, to anso end Prateuerty Code: Tha or impr yes License Lew does not apply to an owner of property who butler or employees,improves thereon, _" and such who does such work himself or through nn own em.1.. 11, however,that wcn ng a' improvement are of intended sold with o,one year ter silo. u, notheoq owner OTHER (SPECIFY) builder or improvement a fold wdnm one year of completion, ma owner builder will have I.the burden of proving that he did not build or improve for poi[] I of tale). PROVIDE I.C.B.O. REPORT NO. I. rs owner of the property, t ( exclusively contracting Pr licensed conin[tors to construct the project (sac 7064, Business and Professions C ode. The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS. .no bu dda or improves maroon, and who contracts lot such projects with e contrectorlfl licensed pursuant to the Contractor's License Law. O 1 em exempt under Sec. ,S.&P C far ma reason APPLICATION DATE, VALUATION PERZIF Owner Dote e— all ,^/ WORKERS'COMPENSATION DECLARATION ®® Buildin V 1 hereby affirm that I have a certificate of consent to sell insure,or a ter �RI ICr Is. o+Workers Compensation Insurance,or a certdud copy thereof Ieec y, N 3800,Lab.C.) Seismic Policy No. Company }y �l o 8 Certified copy is hereby furnished. C1„ IJ4 9r9� Total Cartified copy a filed with the city inspection division P Applicant UFt CERTIFICATE OF EXEMPTION FROM WORKERS' NH k tf�eM IT AUTHORIZATION DATE COMPENSATION INSURANCE (This )or le need not be completed if me Permit a for one n Brad ob lent($f00)o.Iasf.l I certify sh that m me performance OI ma work for which ma permit a issued, shell not employ any parson m a y enna fo a • m•mbI•ct to the or oensauon Lay errorC�� Dote Applicant a NO TI EI E T�ANT. If, after making fNS Certdlnts of Exemption, you should become subiKt to the Workers Compensation provision.of me Labor Code.Vou must forthwith comply with such provisions of this permit .half be deemed evoked. All roofs shall be inspected prior to any roofing materlalbeing r 1 certify that i have read his aoplbation and late that the above informs installed If a roof is Installed without first obtaining an Von is correct. l agree to comply with all city and county ordinances and inspec ion,I agree to remove all new materials for inspection sob lows relating to building construction, and hereby amharixs nOntsm setivo of this city to enter upon the above mentioned property for mapaction ��� /A A (We)liabilities.agree uva, m ts,cos s antl keep es which the City of ay accrue against iy i consequence certf and expenses f this may m any wry.stns. speintf said City in consequence of she granting of snit permit SIGNATURE OF APPLICANT DATE PRE-INSPECTION: PLYWOOD: I N-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 _ _