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R-3886 PERMIT R- 3 8 8 6 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408) 252-4505 EXT. 228 WITH I N 180 DAYS OF WORK NOT OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS - BUILDING USE -J0kv, VVG RESIDENTIAL COMMERCIAL OTHER OWNER'S ROOF NAME !&n RG'_Vtn.�7 FIREARDOUS COVERING A AREA CLASS ADDRESS 1 0 '.:;-ani EXISTING ROOF COVERING PHONE — " 3 NUMBER OF EXISTING COVERINGS 2 CONTRACTOR'S !� (� I' •Z,-_ NAME �'�'� �LSa..S L�:�-711Ly.` I Vl r:- TO BE REMOVED TO BE RETAINED ,�1 ,_ /�, TYPE OF ROOF COVERING CITY&Zi 33D Pli up-LA-✓t- Avr Skil JOSC- 95 17- EXISTING PHONE �)� ) - a!}'�S S BUILT-UP ROOF LICENSE ASPHALT SHINGLES �:*-�+Q-✓ NUMBER .SI O'D WOOD SHAKES % IA.•,1 dam✓ LICENSED CONTRACTORS DECLARATION hereby affirm 7000) of licensed 3underof provisions of Chapter 9(commd, aning with Section 7000) of Division a pi m.9usinxs mtl Prof..ren.cps.. WOOD SHINGLES d mY Iloanx 1 1 full eo w and affect. License Cie. • Z^'� Lic.Number 1. JOI OTHER (SPECIFY) Data •'f.-.10-�� Contracto. OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Lew for PROPOSED the following reason. (Sac. 7031.8, Business and Professions Coda: Any city or county which requires a permit to construct, alter, Improve, demolish,Or repair any structure,prior to its issuance,also requires the applicant for such BUILT-UP ROOF Permit to rile 0 signed statement that he is licensed Pursuant Lo the provisions of Ina Contractor's License Law (Chapter g (commencing with Section 7000) of Division 3 of the Business and Professions Coda)or that he is exempt there ASPHALT SHINGLES from and the basis lot the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to•civil penalty of not more that five hundred dollen( 500).) : WOOD SHAKES ❑ I,as owner or the property, or my employees with wages as their sola compensation,will do the work, and the structure is not intended o offered for Sale(Sac. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES Law does not epPH toe owner of property-no builds or improves th.,oci and who does Such work himself or through his own employees,provided that such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY) building or improvement is tole within one year of completion, the owner builder will neve the burden of proving that he and not build or improve for Purpose of on Sale.). ❑ e owner of the prOp•..r. am exclusively contracting with licensed PROVIDE I.C.B.O. REPORT NO. contractors to construct the project (Sac. 7044, Business and Professions Code: The Contractor's License Low does not apply to an owner ofPropertv PROVIDE MFGR. INSTALLATION SPECS. wino build' or improves thereon, and who contracts for such projects with a contractor( licensed pursuant to the Con[rector.License Law. ❑ I .m exempt ends s.p. ,B.SP.c.for this reason APPLICATION DATE VALUATION PERMIT FEE Owner Data WORKERS'COMPENSATION DECLARATION Building I hereby affirm that I have a certificate of consent to soli insure,or a car. � ( f /y tificate of wor kers' Compensation Insurance,or certified copy thereof(sea I ® Seismic 3800,Lob. .). �C�A1 1 tr I 1� �:1 Policy No. si 22 rebs fCompany FJ1 NC` 'k-a. Total ertiflad copy is nanby fu rnislbtl. Certifies copy i•filad wins th1 city inspection division. ApplicantjUL CERTIFICATE OF INS FROM WORKERS' N C [3P THORIZATION DATE COMPENSATION INSURANCE CITY /� �f / nbis Section need not be cpmpLree ff the Permit is for one nnm.es sol UP tYUI'ChllN ((/ Ian If100f or bs•.1 4 1 certify that in me performance of any work for which co a ubj is lex me, I reel not employ any parson in any men er so as to become Subjxi f. to the Workers'Compensation Laws or California.n Deb Applicant NOTICE TO APPLICANT: hirer reeking this ioof Exemption, you Should become Subject too the Workers' Compensation provisions of the Labor Coda, you must forthwith comply with such provisions or this permit All roofsshall be inspected prlortoany roofing mat/,a reel be dxmad revoked. 1 certify that I hive rase this application and nate that the above informs. Installed. If a roof Is Installed without first obtaining an bon i.laws re L. tofu b comply wits,construction, and .red by out or if. air sed Inspe t' WOA move all new materialsforinspectlon ren ,.. 10ting to buildingplywith.11 and end co Su7nor in rx.exm unves o1 this city b enter upon[M above mentionetl property for inspxtipn �_purposesIW, agrx to Sava, indemnify and xpe es whi h the City of CuPertlo0 againsliebilitix,ludgmenn,cosh see axoensx which they in my way«trueagainst raidCityin consequence of the granting of this permit. y 7 JCANT 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 PERMIT R_ 4065 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408) 252-4505 EXT. 228 WITHIN 1180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS / ^ _\ 1� BUILDING USE / oto l.J�. �1�I F'l ' RESIDENTIAL COMMERCIAL OTHER— OWNER'S THER OWNER\ NAME Is HAZARDOUS�f�. ` �'D 1'T^' HAZARDOUS ROOF FIRE COVERING \ AREA CLASS ADDRESS PZ6 t ^�1`4 CA EXISTING ROOF COVERING PHONE -/72 -'} c��1 f NUMBER OF EXISTING COVERINGS �— o+•J�I' J CONTRACTO S TO BE REMOVED TO BE RETAINED NAME � TYPE OF ROOF COVERING CIsTY&io 11n alp 1nax.9 & UW EXISTING m X114;µ3 BUILT-UP ROOF E PHONnl L�'� 8 Y L 2-- LICENSE 39 'I_22-+� ASPHALT SHINGLES NUMBER T TO WOOD SH LICENSED CONTRACTORS DECLARATION — I bmey affirm that) of Division under provisions DI d Prof 9 F.on.Loam WOOD SHINGLE inp with Section )000) of Division ]of Me Business mtl Prof nfions Coda, and mY Ilcenea full an0 e1Lct. 2-13 License Clan Lic.NumOa J Dasa � connepto OTHER (SPECIFY) OWNER BUILDER DECLARATION I hereby affirm that I em exempt from the Convectors License Law for PROPOSED the following reason. (Sec. 7031.5, Business and Profession+Coda: Any city ✓ reCounty which requires a permit to construct, alter, improve, dem Oli+h,of pair any structure.Prior to its issuance also requires the applicant for suchBUILT-UP ROOF permit to file a signed statement that he is licensee pursuant to Ma provisions of the Contractors License Low (Chapter 9 (commencing with Section)000) of Chr mss 3 01 Me Business and Profession code)or that he is exempt more ASPHALT SHINGLES Irons and the basis lot the alleged exemption. Any viol 1.on a penalty v of no by any t five hu for s permit subjects Me applicant to s cavil penalty of not mo..that fiy.hundred doss...($soo).h ODD SHAKES ❑ I,as owner of Me property,or my employees with wages a Mair sola 1 comp.m.flon,will do the wart, and theess structure is not intended Contractor's License WOOD SHINGLES City /9eQ� _ I.r sale (Sec. )044, Business and Professions Code: The Contremgr'a Licama Lew does not apply t0 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 intended or offered for sale. If, however, the OTHER (SPECIFY) building 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 Purposeof sale.). PROVIDE I.C.B.O. REPORT NO. ❑ I, a+ owner of the property, am exclusively comracting with licensed Contractor: to c nstruct the project (Sac. 7044, Business and Profession+ code: The Comrai License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS. who builds o mprove, [hereon, and who contracts for such projects with a contractors)licenssd pursuant to the Contractor's License Law. ❑ 1 am exempt under Sec. ,B.&P.C.for this reason APPLICATION DATEI VALUATION PERMIT FEE Owner Data WORKERS'COMPENSATION DECLARATION B Iding I hereby eIfirm the, I have•cotific .of consent to..If in sun,or a car ....te of Work.rJ Compametion lnsmenjjye��o. rtlfie pv thereof(Sac. / ` $el 3800, LeD,Com,/rJ 1G'/ �t'{r� J� Policy No ce.rb.d op i+n..aDv wrnisn d. f Total B Car tied fila t t inspect,on division. April icer +a_� CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. C O PERMIT AUTHORIZATION DATE COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred d01 lens(:100)Or nese.) I'V 1 certify100) In in the performance OI the work for which this permit if issued, I shell not employ any parson in any manner so as to become subject to:he Workers'Compensation Lew.Of California. DeU APpliunI NOTICE TO APPLICANT: 11, slier making his Cerbficesa of Eaamption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shell be deemed revoked. All roofs shall be inspected prior to any roofing material being I cartiH he I have reed this application and state that Me above informs. Installed If a roof is Installed without first obtaining an tiPn is Correct. I .grea to comply with all city and county ordinances and inspection,I agree to remove all new materials for inspection. state laws mating to building construction, and hereby euthorixe .Pr...n I live.of this city to anter upon the above mentioned property for inspection ` o \� Purposes. gree n k L IWeI ato ukeepye indemnify end keep harmless the City of Cupertino }1 against liabilities,judgments,costs and expenses which may in any way aC<rue against+aid City in consequence of the granting of this permit. SIGNATURE OF APPLICANT DAT- 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