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R-4151APPLICATION FOR REROOF PERMIT LJ CITY OF CUPERTINO INSPECTION DIVISION (408) 252-4505 EXT. 228 PERT NUMBER Rox 4151 PERMIT EXPIRATION PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING USE OTHER OWNER'S HAZARDOUS ROOF NAMEA& k e r IFIRE REA " CLASS COVERING ADDRESS(�J� - % /� EXISTING ROOF COVERING PHnNF % 1 )S1 C! NUMBER OF EXISTING CJ.VERINGS NAME CA ADDRESS I PHONE 6 4 3 5V 3 LICENSE NUMBER LICENSED CONTRACTORS DECLARATION 1 h ... byy affirm that I em li..... under provisions of Ch.,n, 9 (commem cine with Section )000) of Division 3 of The Business and Prof no s Coda, and my' i full Dand effect. License Cbp Lin. Number 4953y� Data Contractor OWNER -BUILDER DECLARATION I hereby affirm that I e mot from the Contractorf Contractor's License Law or the following reason. (Sec. 7031.6, Business and Professions Code: Any city or county which requires a permit to construct, site, improve, demolish,or rape;, structure, ructure, prior to its issuance, also requires the applicant for such permit to lila a signed statement that he is licensed Pursuant to the provisions of th. Contractor's License Low (Chapter 9 (commencing with Section 70001 of Division 3 of the Business and Professions Code) or that he is exempt Men from and the basis for Ma alleged exemption. Any violation of Section ]031.6 by any applicant for a Permit subjects Me applicant to a civil penalty of not mon Mp at five hundred Colors (S600).): ❑ I, as owns. OI the property, or my employees with wages as Meir sole compensation, will do the work, and the structure is not intended or offend for tele (Sac. )044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds o, 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 building or improvement i sold within one year of completion, the an builder will have the burden of proving that he did not build or improve ior purposeof sale.). ❑ I. as owner of the property, am exclusively com,anting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Lew does not apply to an owner of property who builds or improves Mereun, and who connects for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. ,B.&P.C. for this lesson own., Date W ORKERS' COMPENSATION DECLARATION I hereby affirm that 1 have a certificate of consent to self. insure, o ti ficate of Worker; Compensation Inf enc or n an.1. d copy Thereof (Bac. 3800, L•b ( ' * 1 g Policy No kill 7�t�omp.pY v'� vO%ha I7Certified copy is hereby furnished. Certified copy is filed with ,he city inspection division. Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C. (This section ..it no, be completed if the permit is for one hundred dol Ian ($100) or lass.) I Certify that in Me performance of the work for which this permit is issued, I shelf not employ any parson in any manner so as to become subject to the Wrkari oCompensation Laws of California, Det. Applicant NOTICE TO APPLICANT: 11, at,., making this Certificate of Exemption, you Mould become subject to the Workers' Compensation provisions of the Labor Coda, you must forthwith comply with such provisions or this permit shall be deemed revoked. I Certify that I have read this application and state that the above inform.. tion is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby nrthorixe r.p,..h ,olives of this city to anter upon the above mentioned property for inspection Purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgment., costs and expanses which may in any way •-Clue against said City in consequence of the granting of this permit. TO BE RETAINED EXISTING BUILT-UP ROOF ASPHALT SHINGLES WOOD SHAKES x WOOD SHINGLES OTHER (SPECIFY) PROPOSED BUILT-UP ROOF ASPHALT SHINGLES WOOD SHAKES (� WOOD SHINGLES OTHER (SPECIFY) PROVIDE I.C.B.O. REPORT NO. PROVIDE MFGR. INSTALLATION SPECS. [APPLICATION DATEI VALUATION I PERMIT FEE I -7100 in Ur ­iu 1-2ct A ( All roofs shall be inspected prior to any roofing material being installed If a roof is installed without first obtaining an inspection, I aggrreeeeee ttorremoovvie alllnnew materials for inspection �i Y,liYf�—/. SATE SIGNA OF APPL A 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