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R-397440 0 OFFICE COPY PERMIT R- 3974 APPLICATION FOR CITY OF CUPERTINO NUMBER REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408) 252-4505 EXT '228 WITHIN EXPIRES80 DAS OOF F PERMIT ISSUASTARTED 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS - BUILDING USE A• l/1 �Y� IF RESIDENTIAL COMMERCIAL OTHER OWN ER'S a C ��p HAZARDOUS ROOF NAME �Sa' SIV FIRE COVERING AREA CLASS cpr2 I� \ �11p �� � EXISTING COV ADDRESS. (IIjL)M7y�L 'COY%YNLl%�t�] ROOF NUMBER OF EXISTING COVERINGS � � -7 PHONE " V • ✓ / TO BE REMOVED TO BE RETAINED CONTRACTQp'S , / ^C /1 /�, TYPE OF ROOF COVERING �/Jl/lf 1(J IK"v�]V�I1 NAME cD°vaii6 EXISTING PHONE BUILT-UP ROOF LICENSE8�C' ASPHALTSHINGLE� NUMBER O WOOD SHAKES LICENSED CONTRACTORS DECLARATION 1 hereby affirm that 1 em licensed under previsions of Chapter 9 (comm.h 70 WOOD SHIN S tiny wim s colon of n of the ...iha a asi . and my licmea is In i I erg qivi fact.-; 1 Licari . C a Lic. Number Data Contractor OTH PECIFY) � R -BUILDER DECLARA I hereby affirm that I am exempt from the Contractor's LiceF • • P QPQ$ED ' the following reason. (S«. 7031.5, Business and Professions Code: Any city or county which require. a Permit to construct, alter, Improve, demolish.or O .par env mucmra, prior to in issuance, also require. the applicant for .um UI LT -UP ROO ' P.M., -mto ills a signed statement that ole Is licensed pursuant to the provisions of the Contractor', License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Profession. Code) or that he is exempt more. `— AS ALT e fromand the basis for the alleged a .motion. Any violation of Section7WI.5 by env applicant for a permit ubiacts the applicant to a civil penalty of not more that five hundred dollars ($500).1: WQQ HAKE ❑ I, as owner of me property, or my employees with wages as their sola compensation, will do the work, and the structure is not intended or offered for sale (Sac. 7044, Bushes. and Professions Code: The Contractor'. License WOOD SH LES Law aeras not apply to an owner of property who builds or improves oras thereon, and who tlon such work himself or through his own employee; Provided that r o ,.-VI �1i V�/v�./�l/'/•F/ such improvements are not intended or offered far sale. If, however, the building or improvement is sold within one year of completion, the owner. OTHER (SP builder will have the burden of proving that he aid not build or improve for _ °"'El PROVIDE I. EP RT NO. ❑ 1, "a'olwne the property, with licensed . .0. contactors st t ( ec.7exclusively4.contracting construct the [ (Sec. end Professions Bto an o case: Tbs Contractor's se La t app of property apply fee un and doeswho PROVIDE MFGR. INSTALLATION SPECS. cot who buildsimproves [names, entl wno each Pr esthen lar a project. witM1 e eo ac or( ) licensed actorecLL a La an[ to tM1e Convenor's License Lew. Ci 1 am trip,pea er ❑ am axemat "oder se=. ,6.6P.C. for this reason APPLICATION DATE VALUATION PERMIT FEE r ow her ow eras WORKERS' COMPENSATION DECLARATION Building 1 herby affirm mat 1 have a certificate of consent to self -insure, o P1 Al r' oficon of Workers Compensation Insurance, or a certified copy [hereof fSec. Y- W del Seismic 3800, Lab. C.I. J Policy No. Company copy is hereby furnished, /1 /.r� I' Total eC.,fei.d w thdcid. Certified copy it filed with the city impaction division. WAR 2 19 5 L/ I Applicant PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. ❑ COMPENSATION INSURANCE D - (This section need not be completed if the permit is for one hundred dol. len ($100) or Iess.) I certify that in the performance of the work for which mix permit is Issued, assail not employ any Lenon in my manner to es to become subject n t° the Workers' Compensation Lews of California. Dae Applicant NOTICE APPLICANT: If,o after this of Exam oboes, should Workers' you .Houle b«oma alibi«t to the Workari Compenation provisions of the Compensation Labor code, you must forthwith comply with such provisions or this permit All roofsshall be inspected prlortoany roofing material being shall be deemed ak.d. Icertify that I have reed this application and state that the above informs Installed. If a roof is instalIV without first obtaining an non is correct. I agree to comply with all city and county ordinances and ins eCtlOn, gree t0 remove I new materials for inspection. state ranting to building n., and hereby autnorix6 rep;. ep of popes a] this city m enter upon tna aDOvementipnad ono Lerry for imp«tion enter the above . purpose. al l IW 1 aorea say., indemnify end keep the City of Cupertino against liabilities. judgments. costs and expenses which in env weer accrue s. es which SIGNATURE OF APPLICAl DATE lie, against said City in =an..qu.n=e of the m•neny of this permit. er 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