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R-4052OFFICE COPY PERMIT R- 4052 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT PERMIT EXPIRES IF WORK IS NOT STARTED (408) 252-4505 EXT. 228 WITHIN 180 DAVSOF PERMIT ISSUANCE OR 180 OAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS BUILDING USE RESIDENTIAL ✓/ COMMERCIAL OTHER OWNER'S HAZARDOUS ROOF NAME JO )O_C"-', !"12� C .�S �� 7r ING AREA CLASS EXISTING ROOF COVERING co C� SJ r ADDRESS 2t) L�z�--�!l (, �1 y "- -.5 _ �0 NUMBER OF EXISTING COVERINGS PHONE O` a� CONTRACTOR'S �j TO BE REMOVED � TO BE RETAINED NAME I'i\ �Y-(�,c-1 $•2. ItL���,_.,: Y�',—.. TYPE OF ROOF COVERING —� ADDRESS r--. CITY & ZIP )O -��oSl . ems-.--v­_7�)i r C) DA - EXISTING '7��` BUILT-UP ROOF PHONE S� LICENSEl/ ASPHALT SHINGLES ' NUMBER 7 S/ WOOD SHAKES LICENSED CONTRACTORS DECLARATION I hereby affirm Nat I am licensed under provisions ente Of Chr 9 (co cin. with section 7000) of Division 3 OI Ma Business and Professions coat, WOOD SHINGLES and my license ie n fu ree and efface / �- �i� License clagq Lic'Nor°ner Dau 7;— Contractor OTHER (SPECIFY) 7 OWNER -BUILDER OECLARAT N 1 hereby affirm that I am exempt tram the Contrecto s License Low for PROPOSED the following reason. (Sec. 7031.5, Businee- and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish,or repair any anucture. prior t0 its iuuanca, .1,. requires the applicant for such BUILT-UP ROOF permit to ill. a signed statement that he is licensed pursuant to the provisions of the Contrectoi s License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therm ASPHALT SHINGLES from and the basis for the alleged exemption. Any violation of Section 7031.5 by any allotment for a permit subjects the applicant to a civil penalty of not mor. Nat five hundred dour. MEOW.): WOOD SHAKES C3I, a of me property. or my employees with wages as Mair sola compensation, will do the work, and the structure is not intended or offer" for .810(Sec. 7044, Business and Profession% Code: TheConnactors License WOOD SHINGLES Lew does not apply to an owner of property who builds or Improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY) building or improvement i ..to within one year of completion, the owner bull Car will have the burden of proving that he did not build or Improve for purpose of sale.). PROVIDE I.C.B.O. REPORT NO. ❑ 1, as owner of the Property, am exclusively Contracting with licensed contnctu. to construct Na project (Sec. 7044, Business and Professions cod•: The Contracer'.Licansa Law do.,no, apply 1..nown.,ofproperty PROVIDE III INSTALLATION SPECS. who builds or improves Neroun, and who contracts for such projects with a contractor($) licensed pursuant to the Contractor's License Law. ❑ 1 am exempt ender sec. ,B.aP.c. for this owner PPLICAT ON DATE VALUATION PERM EE Date WORKERS' COMPENSATION DECLARATION I hereby affirm that 1 have a certificate of consent to self -insure, r a Cer �fnB X7,0 R Building tiliceb of Workeri Compensation In. anp•, Ora Carti ed cop [hereof ($ac. 3800, Lab, i.F. 1 U er 'i� Seismic Policy Qj-� QI�1 Company copy is hen / (k V /� Total FrCartili.d Certif mad cop .is rty inspection division. (.yU� Applicant IT AUTH DATE CERTIFICAT F OXEMPTION FROM WORKERS' N.C. ❑ COMPENSATION INSURANCE (This section need not be completed if the permit is for One hundred dol Ian (5100) Or leal I Certify that in the performance of the work for which this permit is issued, I shell not employ any person in any manner so as to become subject to Na Workers' CDmpensetion Laws of California. silo DateApplicant — NOTICE TO APPLICANT: If, afur making this Certificate of Exemption, You Mould become subject t0 the Workers' Compensation provisions of the Labor Coda, you must forthwith comply with such provisions or this permit All roofs Shell b@*nafp cte prlouto any roofing material being shall be dsemed revoked. '' 1 certify Mat 1 have read this application and state that the above inform. insttalled. If a roof 1 without first obtaining an ,on I. correct. I agree to comply with all city and county ordinances and ins actio I o all new materialsfor inspection. nate laws relating to building construction, and hereby nnhorl se reprenem .liver, of this city to enter upon the above mentioned property for inspection purpose. (We) agree save, in antl keep es the City of Cupertino against liabilities, ts, cos s Which ensu and expanses may In any way accrw glbgATUE OF APPLICANT I DATE aiCyi consequence f this against said Citym ponogeene of me gaming of this permit. 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 OFFICE COPY PERMIT R- 4052 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT PERMIT EXPIRES IF WORK IS NOT STARTED (408) 252-4505 EXT. 228 WITHIN 180 DAVSOF PERMIT ISSUANCE OR 180 OAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS BUILDING USE RESIDENTIAL ✓/ COMMERCIAL OTHER OWNER'S HAZARDOUS ROOF NAME JO )O_C"-', !"12� C .�S �� 7r ING AREA CLASS EXISTING ROOF COVERING co C� SJ r ADDRESS 2t) L�z�--�!l (, �1 y "- -.5 _ �0 NUMBER OF EXISTING COVERINGS PHONE O` a� CONTRACTOR'S �j TO BE REMOVED � TO BE RETAINED NAME I'i\ �Y-(�,c-1 $•2. ItL���,_.,: Y�',—.. TYPE OF ROOF COVERING —� ADDRESS r--. CITY & ZIP )O -��oSl . ems-.--v­_7�)i r C) DA - EXISTING '7��` BUILT-UP ROOF PHONE S� LICENSEl/ ASPHALT SHINGLES ' NUMBER 7 S/ WOOD SHAKES LICENSED CONTRACTORS DECLARATION I hereby affirm Nat I am licensed under provisions ente Of Chr 9 (co cin. with section 7000) of Division 3 OI Ma Business and Professions coat, WOOD SHINGLES and my license ie n fu ree and efface / �- �i� License clagq Lic'Nor°ner Dau 7;— Contractor OTHER (SPECIFY) 7 OWNER -BUILDER OECLARAT N 1 hereby affirm that I am exempt tram the Contrecto s License Low for PROPOSED the following reason. (Sec. 7031.5, Businee- and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish,or repair any anucture. prior t0 its iuuanca, .1,. requires the applicant for such BUILT-UP ROOF permit to ill. a signed statement that he is licensed pursuant to the provisions of the Contrectoi s License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therm ASPHALT SHINGLES from and the basis for the alleged exemption. Any violation of Section 7031.5 by any allotment for a permit subjects the applicant to a civil penalty of not mor. Nat five hundred dour. MEOW.): WOOD SHAKES C3I, a of me property. or my employees with wages as Mair sola compensation, will do the work, and the structure is not intended or offer" for .810(Sec. 7044, Business and Profession% Code: TheConnactors License WOOD SHINGLES Lew does not apply to an owner of property who builds or Improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY) building or improvement i ..to within one year of completion, the owner bull Car will have the burden of proving that he did not build or Improve for purpose of sale.). PROVIDE I.C.B.O. REPORT NO. ❑ 1, as owner of the Property, am exclusively Contracting with licensed contnctu. to construct Na project (Sec. 7044, Business and Professions cod•: The Contracer'.Licansa Law do.,no, apply 1..nown.,ofproperty PROVIDE III INSTALLATION SPECS. who builds or improves Neroun, and who contracts for such projects with a contractor($) licensed pursuant to the Contractor's License Law. ❑ 1 am exempt ender sec. ,B.aP.c. for this owner PPLICAT ON DATE VALUATION PERM EE Date WORKERS' COMPENSATION DECLARATION I hereby affirm that 1 have a certificate of consent to self -insure, r a Cer �fnB X7,0 R Building tiliceb of Workeri Compensation In. anp•, Ora Carti ed cop [hereof ($ac. 3800, Lab, i.F. 1 U er 'i� Seismic Policy Qj-� QI�1 Company copy is hen / (k V /� Total FrCartili.d Certif mad cop .is rty inspection division. (.yU� Applicant IT AUTH DATE CERTIFICAT F OXEMPTION FROM WORKERS' N.C. ❑ COMPENSATION INSURANCE (This section need not be completed if the permit is for One hundred dol Ian (5100) Or leal I Certify that in the performance of the work for which this permit is issued, I shell not employ any person in any manner so as to become subject to Na Workers' CDmpensetion Laws of California. silo DateApplicant — NOTICE TO APPLICANT: If, afur making this Certificate of Exemption, You Mould become subject t0 the Workers' Compensation provisions of the Labor Coda, you must forthwith comply with such provisions or this permit All roofs Shell b@*nafp cte prlouto any roofing material being shall be dsemed revoked. '' 1 certify Mat 1 have read this application and state that the above inform. insttalled. If a roof 1 without first obtaining an ,on I. correct. I agree to comply with all city and county ordinances and ins actio I o all new materialsfor inspection. nate laws relating to building construction, and hereby nnhorl se reprenem .liver, of this city to enter upon the above mentioned property for inspection purpose. (We) agree save, in antl keep es the City of Cupertino against liabilities, ts, cos s Which ensu and expanses may In any way accrw glbgATUE OF APPLICANT I DATE aiCyi consequence f this against said Citym ponogeene of me gaming of this permit. 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