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R-4056 PERMIT R- 4056 APPLICATION FOR CITY OF CUPERTINO NUMBER R- DIVISION PERMIT EXPIRATION REROOF PERMIT (408)) 252-252-45055EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN80 DA S F OM LASAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS BUILDING USE RESIDENTIAL / COMMERCIAL OTHER OWNER'S HAZARDOUSOOF NAME Z DS S^\ �I�n,� FIRE COVERING AREA CLASS ADDRESS Q T L�Tx ^D����<Y bQ��rr LIQ EXISTING ROOF COVERING PHONE :;L— C NUMBER OF EXISTING COVERINGS CONTRA TOR'S TO BE REMOVED� TO BE RETAINED NAMEIM TYPE OF ROOF COVERING DD CIT aiih 103Co� �Qc9 r-��E{v�-�1 (� .EXISTING PHONE IA ' 2915 -A4 ` BUILT-UP ROOF LICENSEccs! 3s� ASPHALT SHINGLES NUMBER JJ WOOD SHAKES LICENSED CONTRACTORS DECLARATION I nappy Section that I of Division under provisions of Chapters ons(commen.Cod mg with secRpn 70001 or Diyl.ion 3 or m.Business and Professions cod., WOOD SHINGLES and my Ilcenu i in lu4 a ane affect. Llum Class \ Lic.Number Data a convwaor OTHER (SPECIFY) OWNER-BUILDER DECLARATION I homy affirm met I am exempt bpm the Contractor's License Law for PROPOSED the following reason. (Sec. 7031.8, Business and Professions Code: Any city or county which requires a permit to c nstruct.alter. Improve, demolish,or repair any structure, prior to its issuance,also requires the applicant forsuch BUILT-UP ROOF permit to RIs a signed statement that he is licensed pursuant to the provisions .,n Of the Contractor's ft License Law(Chapter 9 (commencing with Section 7000) firm Division 3 of me Business dna alleged exemption.)or that he is exempt more ASPHALT SHINGLES from end the basis for me apermi exemption. Any violation of Section of hot o any applicant fora pomp subjects me applicant to a civil penalty of not more twat rive the redpro erty, r my em WOOD SHAKES ❑ I,as owner of ,tie property, or my employees with wages as their sola compensation,will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Coda: The Contractors License WOOD SHINGLES Lew doe 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 Mile. If, however, the OTHER (SPECIFY) building or improvement is sold within one year of completion, the owner builder will neve the burden of proving that he did not build or Improve for ' Purposeofaal.1. PROVIDE I.C.B.O. REPORT NO. ❑ I, as owner of the property, em exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Profession% ode: The Contractor'sLicenseLowdoesnotapplytoanownerofproperty pROVIDEMFGR. INSTALLATIONSPECS. who builds or improves theraun, and who contracts for Such projects with a contrec for(S)licensed pursuant to the Contractor's License Law. ronin I em exempt under Sac. ,B.&P.C.for this Own. Date PPLIdAtION-DATE VALUATION PERM EE WORKERS'COMPENSATION DECLARATION JUN y 1 �1f���JvL'11/� Building 1 h.r.by affirm that I have a certificate of con. t,o salt ln.ur 1995 N/'-� tifica,a of Workers Compensation Insuran or c tit ac pymeraof(Sac, Seismic 3600,Lab. ,n tfl__}_ () ^/f PBOB Awe ?.)�l Company��LLR\U C 111�1e� lx G l Certified Copy is hereby furnished. UrEk rlNp Total ` Certified copy is filed with the city inspection division. Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.C1PERMIT AUTHORIZATION DATE COMPENSATION I INSURANCE (This Action nee not be completed if the permit is for one hunmed doL tars(S1 W)or leas.) I certify that in me performance of the work for which [his permit is issued, I Shall not employ any person in any manner to as to become subject to the Work.,.Compensation Laws o1 California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers Compensation provisions of the Labor cod.,yougat forthwith comply with .q<n provisions or,ni.perms, All roofs shall be in ted prlortoany roofing material being se.0 b.%..mea revoked. I certify that 1 have read this eppllution and state he, he above inform. Installed If of ' I ed without first obtaining an Ren is Correct. 1 .gra 10 Comply with all city and county ordinances and Inspection t Va all new materials Porins action state law. ral.iing to building conftructi on, and hereby etimcnixe repref.m P P tativas of this city,o enter upon the above mentioned property for inspection purposes. f17 (We)l agree to siva, indemnify and keep harmless a City o1 ay accrue against said Cbas, consequence tet cotta dna expenses which they In any way accrue ewimm oia ctry in<on.equenge of me granting of this permit. SIG AT E O 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