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R-4164APPLICATION FOR REROOF PERMIT c� BUILDING ADDRE: '012, /9sc OWNER'S NAME ADDRESS PHONE J CONTRA R'S NAME �� CIITDY RESS & ZIb//6i PHONE LICENSE NUMBER 77 !! CITY OF CUPERTINO INSPECTION DIVISION (408) 252-4505 EXT. 228 M LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions o1 Chapter 9 (co cin, with Section )000) Of Division 3 of the Business red Profeun Code, antl my Ilcense 1 r0a and effect 1�J3 35 License sk Lic. Number Date— PIContrecror ONE R BUI LDER DECLARATION tOl I hereby affirm that I em exempt from the Contractor's License Law for the following reason. [Sec. 7031.6, Business and Professions Code: Any city or county which requires a permit to construct, alto, improve, demolish,or ,lips ir any structure. Prior to in issuance, also requires the applicant for such permit to Iib a signed statement that he Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (Commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt there from and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit Subjects the applicant to a civil penalty of not more that five hundred dollars ($500).): ❑ I, as owner of the property, Or my employees with wages as their sole compensetion,will do me work, and the structure is not intended or offered for sale [Sec. ]044, Business and Professions Code: The Contractor's License Lew do. not apply t0 an owner of property who builds or improves thereon, and who don such work himself or through his own employees, provided that buch improvements are not intended or offered for sale. If, however, the ilding or improvement is sold within one year of completion, the owner builder will have the burden of proving that he did not build or improve for purpose of aaleJ. ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sac. 7044, Business and Professions Code: Tha Contraclor f License Law does not apply to an Owner Of property who bu ildf or improve% thersun, and who contracts for such projects with a contractor($) licensed pursuant to the Contractor's License Law. ❑ 1 am exempt undo, Sec. ,B.&P.C, for this WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to self insure, or a wr tificate Of Workers' Compere tion Insurance, or a certified copy thereof (Sec. 3800, Lab. C.). Policy No. Company eCertified copy 1, hereby furnished. Certified copy is filed with the City Inspection dlvisi on. Applicant CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION I NS URANCE N.C.0 (This section need not be completed if the permit is for one hundred dol bra (5100) or Int.) I certify that in the performance Of the work for which this permit is Shall issued. I not employ any person in any manner so as to become subject 10 the Workers Compensation Laws Of California. Date Applicant NOTICE TO APPLICANT: If, ofser making this Certificate of Exemption, you should become subject to the Workers Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit Shall be deemetl revoked. I certify that I hrva reed this application and state sun the above inform. tion if correct. I agrse to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize repnfem btivn of this city to enter 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 expenses which may in any way accrue eainst $aid City in consequence of the granting of this Permit. NUMB R R- 4164 PERMIT EXPIRATION PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING USE 6 NUMBER OF EXISTING COVERINGS 0/0 �— EXISTING BUILT-UP ROOF ASPHALT SHINGLES WOOD SHAKES X WOOD SHINGLES OTHER (SP CIFYY)4 / ID PROPOSEDY BUILT-UP R�1?OFU�Fyr99tS ASPHALT SHINGLES NO WOOD SHAKES P-4 y� .f 'o WOOD S M/0*0 OTHER (SPE&(Y,) s199S UN,c PROVIDE I.C.B.O. RE 9p)T NO. PROVIDE MFGR. INSTALLATION SPECS. [APPLICATION DATEI VALUATION I PERMIT FEE I � (G 2 CI Building Seismic lO f . ? O Total 7o /0 I PERMIT AUTHORIZATION I DATE I All roofs shall be inspected priortoany roofing material being installed If a roof is installed without first obtaining an Insp71� agree to remove all new materials for insp ction �� /� 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