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R-3992 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- 39 9 2 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (40$) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTER WITHIN IN GAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS BUILDING USE s-- (1 IC IY iL a5 P RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZROOF NAME � n r-7'1'4 `7 F(� FIRE COVERING COVVERING AREA CLASS ADDRESS LL6 7 .P -� �� M �FZLO�- ,Dl� EXISTING ROOF COVERING PHONE V\ — 0-aQ� NUMBER OF EXISTING COVERINGS CONTRACTOR'S i TO BE REMOVED TO BE RETAINED NAME leepoV/hQ Q7 ed9oo � TYPE OF ROOF COVERING ADDRESS CITY&Zlb 1971.3; %,,ze�r-/! Ilesm GU�E/zT//`io SEXISTING PHONE rJ© 421 -0 72 BUILT-UP ROOF LICENSE ASPHALT SHINGLES NUMBER S 3 16 WOOD SHAKES LI LENSED CONTRACTORS DECLARATION I McDY eHirm the,I em licensed under Prov lsions o/Chapter 9 Icommam bg with Section 7000) of Division 3 of the Business and Probations Code. WOOD SHINGLES and my Iicanee b ull f i n affect. Daanse Clan - Co.Numb; Data - conmecto. OTHER (SPECIFY) O NER.BUILDER DECLAR N I hereby affirm that I em exempt from the Contractor's License Law for PROPOSED the lollowing reason. (Sec. 7031.5, Business and Professigm Code: Any city or county which requires a Permit to conduct,alto, improve, damolisn,or ^ p I9 I D repair any structure,prior to its issuance.also requires the applicant for such BU LT-UP ROOF IP permit o Coniletractor's tsi's Li statement thatheis licensed(commencing pursuant to the ftion 7100) Pi the Contrectoi s License Law that h 19 lensedendng with Section ivans /(�� .��n(�p(� of Division 3 of the Business and Professions Code)or that he is exempt mere ASPHALT SHINGLES MR 10 1995 from and the basis for the alleged a amplion. Any violation of Section 7031.5 by any applicant for a Permit subjects the applicant to e civil penalty of not more that five hundred dollars( 5o0).): WOOD SHAKES ❑ 1,as owner of the properly, or my employees with wages K their sole compensation,will do the work, and the structure is not intended or offered 'CI I Y ur wrcrt I INU for sole(Sec 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES Law does not apply to an owner of properly who builds or improves thereon, and who does such work himself or through his own employees,Provided that such improv mats are not intended oroffered for sale. u, however, the OTHER (SPECIFY) building Or improvement is sold within one year of completion, the owner for builder will have the burden of proving that he did not build or improve Purpoat of sale.) . PROVIDE I.C.B.O. REPORT NO. ❑ I, s owner of the property, am exclusively contracting With licensed contractors to construct the Project (Sac. 7044, Business and Professions ode: The Contractor's License Law doasno,apply wanowner ofproperty PROVIDEMFGR. INSTALLATIONSPECS. Who builds or improves thebun, and who contracts for such projects with a contractors)licensed Pursuant to the Contractors License Law. ❑ I .m exempt under Sec. ,asepses for this reason APPLICATION DATE VALUATION PERMIT FEE Owner Data WORKERS'COMPENSATION DECLARATION Building )ua I hereby affirm that I have a certificate or consent to self insure,or a car ` Q/ tilieeh.of Workers Compensation Insurance, r certified copy merepf(Sec. / III �.. 3-1a -y.r jo a Seismic 3800,Lab. o �� Poli<Y No. moony ha 'Y� Total Iyy CeRilied coot hereby iurnisMtl. T Certified copy is filed wise the city inspection division. Applicant CERTIFICATE OF EXEMPTION FROM WORKE PERMIT AUTHORIZATION DATE COMPENSATION INSURANCE N. ITnis saction neea not be compl.bd ff ma permit is one Hundred d Ilrs(5100)or Iess.l I certify that in the performance of the work which this permit is sued, 1 shell not employ any pernn in any me r so aI to stoma sub,. �� to the Wo Compensation Laws of Celilorn' . Deb ApPliGant NOTICE TO APPLICANT: If, after m ng this Card I 1 you should become sutij., 10 tea Wor a i Compenutio 4g�t of m! Labor deemedrevoX rormWitn mom ywitn .um provisio or loo pandit All roofs shall be inspected prior to any roofing material being anal)be deemed evoked. V certify that I have had this aVpli tion and b ere me ayes informa Installed. If a root Is Installed without first obtaining an tion is correct. l agree to comply WI nl city ou? 'dine n<es a inspection,I agree to remove all new materials for inspection sbte laws elating to building construct v �,TIt hie r Prn m tetives of this city to anter upon tea above nti rope V for impe Ion we)liabilities,agree save,udg int$,COSy and keep nmless h City of Cu mind {`/y`-[1 against id iy i juo consequence cosh and flaming high In nY Wa KCIUI against aid City in comnwnce of ma gnnling o his permit. GNATUR PLICANT DATE PRE-INSPECTION: P LL2'llROD: IN-PROGRESS: INSP. DATE INS 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