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R-4188 PERMIT R- 418 8 APPLICATION FOR CITY OF CUPERTINO NUMBER R- PERMIT ' NSPECTIONDwsioN PERMIT E PEMIT EXPIRES OF ORKI N OT (408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT SUAT CETOR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS BUILDING USE qafiQSP� O`�O ` z RESIDENTIAL COMMERCIAL--/�L OTHER OWNER'S NAME ^ "" �'`( FIREARDOUS ROOF COVERING CLASS �1 / AREA EXISTING ROOF COVERING ADDRESS, 12,-7-72 S'1A-2.` S v�L P-0t)00 PHONE / �[ 9�7D NUMBER OF EXISTING COVERINGS CONTRACTOR'S /� JAI Roo F, . L TO BE REMOVED TO BE RETAINED NAME J t.7 I\ N- 7 TYPE OF ROOF COVERING ADDRESS f>0 goy( 9�3 C6-M n EXISTING PHONE �! / BUILT-UP ROOF LICENSE '1 ASPHALT SHINGLES NUMBER / WOOD SHAKES LI CENSED CONTRACTORS DECLARATION I hereby off irm that I am licensed under provisions of Chapter 9(common cmg with Section 7000) of Division 3 of me Businayla Pro.�,�grla Fyde, WOOD SHINGLES no my Ilpnse is,its fu7Lio�sed aflecL cam( / License Cliff C� �.l _ Lic Number Date 70 s— Contractor �+ ti OTHER (SPECIFY) OWNER-BUILDER DECLARA ION I hereby affirm that 1 am exempt from the Contractor's License Law for PROPOSED the following reason. (S«. 7031.6, Business and Professions Code: Any city 01 county which require$ a permit t0 Construct. sitar, improve, dem Olish,or /�L\ repair any atmcture,prior to its issuance also requires the applicant for such BUILT-LIP ROOF Permit t0 nIs a signed statement that ate is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) oI Division 3 of the Business and Professions Coda)or that he is exempt mere ASPHALT SHINGLES from and the basis for the alleged exemption. Any violation Oi Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty Of not mice that five nu ndred dollars(9500).): WOOD SHAKES ❑ I, as owner of the property, or my employees with wage$es their$Ole compensation,will do the work, em me structure is not intended or offered WOOD SHINGLES for sale(Sec. 7044, Business and Professions Code: The Contractor's License Lew does not apply to an owner Of property who builds or improves[hereon, and who does such work himself or through his Own employees,Provided that such improvements are not intended or offered for sale. u, however, the OTHER (SPECIFY) building or improvement is sold within one year of completion, the owner. builder will have the burden of proving that he did not build or improvefor purpose of sale.). PROVIDE I.C.B.O. REPORT NO. ❑ I, a owner of the property, em exclusively contracting with licensed contrac ton to construct rhe project (Sec. 7044, Business and Professions od.: rneconvac[oraucenseLowdoes not apply toanowner ofProperty PROVIDE III INSTALLATION SPECS. who builds or improves meoun,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑ 1 am exempt under S.C. ,B.&P.C.for this reason APPLICATION DATE VALUATION PERMIT FEE Owner Do,.— WORKERS: auWORKERS'COMPENSATION DECLARATION-inyLia Building 1 to at affirm that have i n Insurance of r a cess, ie self copy ache, �"{ 0 J of00, Of Workers'Compensation Imm��nc/e}or-,--c�.er�[ilied�c`oPY meregi(Sec. O� ,L /1 �L..J Sal$mIC r 3800,Lab .).T.l !W �( /'y% C C UN E/�J\ / 1/`v Policy Np��,�yp Company 3l/(� I] C.rtified copy b hereby fumi.h.d. _ / ` 1 Total C.hfiais copy is+ilea with the city inspection division, Applicant V CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. C 0 VVrP-ERMITAUTHORIZATION DATE COMPENSATION INSURANCE '1 (This($ 0 r,lei head not be completed it the permit is for one hundred d06 I yLVy los 1 cerci or less.) I certify inet in the performance OI the work for as which .. permit it toted. I shall not employ any Lenon in any manner so as[o became subject to the Workeri Compensation Applic Lawt of California. Data NT: if, NOTICE should APPLICANT: o afar making this Danif n p of Eons of the you thould b«oma ab)«t to [M1a Workers'Compensation provisions o1 Ina Labor Code, you must forthwith comply with such provisions or this permit All roofs shall be inspected prior to any roofing materialbeing an all be doomed revoked. I certify that I have road this application and state that the above informs installed If a roof Is Installed without first obtaining an don is Correct. 1 agree to comply with all city and county ordinances and ins p ction,I agree r ve all new materials for inspection. state laws relating to building construction, and hereby authorize repress. /�{nJp n[ives of this City to enter upon[M above mentioned property for imp«tion Q�� purpose. rlY/ 'W�" r • �VN/rN�'/rte �V%L_ / J (We) agree to save, indemnify and keep harmless the City of Cupertino .,.ins liabilities, judgments.costs and expenses which may In any way accrue .,int:tam City in consequence of the granting of this Permit, SIGNATURE OF APPLICANT DATE . PRE-INSPECTION: PLYWOOD: IN-PROGRESS:- INSP. 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