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R-3719L-1 PERMIT 3 719 APPLICATION FOR CITY OF CUPERTINO NUMBER R� INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN IN DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. 4o t ao OWNER'S NAME ADDRESS 1116,6 / 3 6.6 -6330 / bis t ­Lf lylnn(aj l v_ . Qom, NAME / X49` P-000 F`1 CITUaSS ? 0 `�`�It 963 efl-Ml`� goocJ PHONE Z(�S Si4 7 as 10 LI CENSED CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter 9 (common cin, with S«tion 7�000I) f Division 3 of the Business and d Pt •Code, and mV Ilcensa f�ln i s(�11. and apace % •io License Cl.es Lic. Number YJ Oen Contractor WNER-BUILDER DECLARATION [hereby affirm that 1 em exempt from the Contnctoi • License Law for the fouowi ng reason. (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish,or repair any structure, prior to Its issuance also reOuires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions o1 the Contractor's License Law IChapar 9 (commencing with Section 7000) 01 Division 3 of the Business and Professions Code) or that he is exempt there. from and the basis for the alleged exemption. Any violatiof Section 7031.5 by any aPPI cart for a permit subjects the applicant to a civil penalty of not mar. that five hundred dollar. ($500).): ❑ I, as owner of the property, or my employees with wages as their sole Compensation, will do the work, and the structure is not intended Or offered for ale (Sec. 7044, Business and Profession$ Code: The Contractor's License Law 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 ins provements are not intended or offered for sale. It, however, the bui:din, or improvement is sold within one year of completion, the owner builder will have the burden of proving that he did not build Or improve for purpose of sale.). ❑ I, as owner of the Property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Bwiness and Professions C6tla: The Contractor License Lew does not apply to an owner of property who buiIds improves theroun, and who contracts for such projects with a contractor($) licensed pursuant to the Contractor's License Law. EJ 1 am exempt under Sac. ,B.BP.C. for this WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to sell,inanrs, o tilitats of Workers Compensation Insurance, /� certified copy th�q)eof (Sac . 3800, Lab. g _q0 ompenv z` "I �� �U� Policy N �T Certified coo is hereby furnished. ` c.nl(ied filed with t� ty divisioe A ants o nAOYs (re '. _�i�s -• C IFICATE OF EXEMPTION FROM WORKERS' N.C. COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred doer ,ars 151001 or Isi l I certify that in the performance of the work for which Ili is permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Data App,icam NOTICE TO APPLICANT: If, after making this Certificate of Exem PHOo, you should become subject to the Workers' Compensation provisions of the Labor Coda, you must forthwith comply with such provisions or this permit Shan be deemed revoked. I certify that I have read this application ane state that the above informs tion is coned. I agree to comply with an city and county ordinances and nate laws relating to building construction, and hereby authorize reproven [olives of this city to anter upon the above mentioned property for inspection purposes. (We) agree 1. save, indemnify and keep harmless the City of CUP*"= against liabilities, lodgments, W dgmnts, costs and expenses which may In any e, Six, Us against said City in conseguence of the granting of this permit. XCOMMERCIAL EXISTING ROOF COVERING NUMBER OF EXISTING COVERINGS / TO BE REMOVED TO BE RETAINED TYPE OF ROOF COVERING EXISTING BUILT-UP ROOF ASPHALT SHINGLES WOOD SHAKES 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 A ABuildin 1 Seismic 51 ion, Z Tnt.1 All roofs shall be inspected prior to any roofing material being installed If a roof is Installed without first obtaining an ov n ew materials for Inspection. I agree to rn �j na All 7 -04 SIGNATURE OF 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