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R-4429 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R— 4429 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT N PERMIT EXPIRES IF WORK IS NOT STARTED (408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS BUILDING USE _ RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZ ROOF NAME +.� Ci/`C- FIRE COVERING COVVERING AREA CLASS ADDRESS ` n'� ( ^' r EXISTING ROOF COVERING NUMBER OF EXISTING COVERINGS PHONE CONTRACTOR'S � © e TO BE REMOVED TO BE RETAINED NAME nn r�/`OS• V� � ppC1 / TYPE OF ROOF COVERING ADDRESS 3f3 /JIY��- �r t✓ r/�JGfca� EXISTING PHONE Yom-33P- 9 BUILT-UP ROOF LICENSE �/(�'/pp ASPHALT SHINGLES NUMBER 110 r� WOOD SHAKES LICENSED CONTRACTORS DECLARATION thDy affirm that I licensed under r provisio ns of 9(common Ting with Section] of Division 3 of the Business and Prof..aons Cods, WOOD SHINGLES and ful c.and affect License ao iocnNm Date `2/-g OTHER (SPECIFY) OWNER-BUILDER DECLARATION I hereby affirm he, I am...met from the Contractor', License Law for P OSED the following reason. (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit t0 construct, alto, improve,d•molisn,or Unears any structure,arrear to ns hwanca,al...anpiro theappncm\to,such UP> ROOF permit to filo a signed statement that he is licensed pursuant to the provision. / of the Contractors License Law(Chapter 9 (commencing with Section 7000) A/%J of Division 3 of the Business and Profession Code)a,me\he I....mpt her. S< (ALT SHINGLES from and tna basis for the alleae0 exemption. Any violation o1 Section L 1031.5 by any •pylic ant fora permit subjects the applicant to a civil penalty of not or tont Live hundred dollen(9500).): WOOD SHAKES ❑ I, .owner o1 the property, or my employees with wag•s es their sole compensation,will do the work, and the Structure is not intended o offered for..I. (Sec. 7044, Bu.ino.and Prnfes.ipn.Code: Th.Connector'.Lic...a WOOD SHINGLES Lew 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 improvements are not 'mtended or offered for Sale. If, however, the OTHER (SPECIFY) building or improvement .old within one year o1 completion, the owner builder Will have the burden of proving that he die not build or improve for Purposepf..I.J. PROVIDE I.C.B.O. REPORT NO. ❑ I, as owner of the property, am exclusively contracting with licensed cantractors to construct the project (Sec. 7044, Business and Professions ode: The Contractors License Law does not apply 1.an Ownv of property PROVIDE III INSTALLATION SPECS. wnq bu dm or improves mereun, and who contracts for such Projects with a cgmractor(s)licensed Pursuant to me Contractor's License Lew. ❑ em ...met under sec. ,B.aP.c.for to i+ PPLIC TION DATE VALUATION PERMIT FEE ....n Ow..,--- Dau tTs WORKERS'COMPENSATION DECLARATION Building I hereby affirm that I how*a certificate of consent to sell insure,o a� tilica\e of Worker)Compansn ion Insurance,or acertified copy thereof(Sec. IstP( �� ��� Seismic 1 0800,Lee.C.). Nr '� Policy No. Company e Certified copy is hereby furnished. bee c.rd copy is filed with the city inspection division. C° Y Ur Lk� Total Applicen\ + CERTIFICATE OF EXEMPTION FROM WORKERS' N C ❑ PERMIT TION DATE COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dol- l...IS 100)ar Ian.) Z 1 certify that in the Performance of the work for which this permit if issued, I .hell not employ any persony en s es to become subject to the Wprkeri COmpansation Lew. Data Applicant C l� NOTICE TO AP LICANT: 11, oft.r making theescis f Exemption, you should become subject t0 the Worker)Compensation provisions of the Labor Cade, You most forthwith comply with such provi.mns or this permit shell be deemed revoked. All roofs shall be inspected prlorto any roofing materiel being I certify that I have read this application and stale that the above inform.- Installed If a roof Is Installed without first Obtaining an tion i. Follett. I agree to comply with ell city and county ordinances and Inspection,I agree to remove I new materials for inspection. pure sews relating to building construction, and hereby authorize r•pratem vtiv«of this city to enter upon the above mentioned property for inspection Purposes IW 1 agnea liabilities, udg intsmnily and xpe Insrinloss which the CHV of Cupertino eaalnst aiCityi judgments,coos and expenses which they In any way accrue .winrz sera City in conwpuanc•of the glinting of This permit. SIGNATURE OF APPLICAW 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