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R-4173 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- 417 3 REROOF PERMIT - INSPECTION DIVISION PERMIT EXPIRATION (408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 1B0 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS BUILDING USE RESIDENTIAL COMMERCIAL OTHER OWNER'S OOF NAME L-a-��l/�/�I m� +- .r -a&!2, -J�� © iih A FIRE HAZARDOUS COVERING 01 AREADDRESS Ip?kll l� /y� {yJ &!2 e P 601 EXISTING ROOF COVERING PHONE ��i T �'^Sc�-� �( O �O NUMBER OF EXISTING COVERINGS CONTRACTORn D TO BE REMOVED TO BE RETAINED / NAME K `�'�nG• TYPE OF ROOF COVERING DD�ZSa '7rale (rrt EXISTING PHONE � �Q2 BUILT-UP ROOF � LICENSE /„/1 f+� ASPHALT SHINGLES NUMBER & WOOD SHAKES /I'IOC�/Ib.GY1] LICENSED CONTRACTORS DECLARATION I hereby eflilm that I am licensed undes Provisions 01 Chapter 9(commen cine wish Section 7000) o1 Division 3 of roe B s rad P.of.ssion.Coda, WOOD SHINGLES and my license is I fu I ore n effect. ��'10� Data Class Li b•r " OTHER (SPECIFY) Date COn\ra[\Or OWNER-BUILDER DECLARATION I hereby eflilm that 1 am...mp\ nom the ContnctorY License Lew for PROPOSED the following reason. (Sec. 7031.5, Business and Professions Coda: Any city, or county which requires a permit to construct,alter, improve, demolisn,or repalr any structure,prior to its issuance, also requires the applicant for such BUILT-UP ROOF P.= to flle a signed statement that he is licensed pursuant to he provislonf of the Contractor's License Lew (Chapter 9 (commencing with Section)000) from Division 3 of the Business and ged exemption, tion, or that he is n of there ASPHALT SHINGLES bosh and the basis for Na alleged esions od Any violation of exempt )031.6 by any applicant for a permit subjects the applicant to°civil penalty of not more that five hundred dollars( 600),1: WOOD SHAKES 0 I, as owner of Ne property, or my employees with wages as their sole compensation,will do the work, and the structure is not Intended or offered for sale (Sec. )044, Business and Professions Code: The Contractor's License WOOD SHINGLES Law does not apply to an owner of property who builds or improves thereon, ,y and who does such work himself or through his own employees,provided that such improvements a not intended or offered for sole. n, however, the OTHER (SPECIFY) •�C.C.../a.l Tj}7-f'l 1 �4 building or improvement is sold within one Year of completion, the owner. budder will neve the burden of proving that he did not build or improve for Pumoseef s°'°,). PROVIDE I.C.B.O. REPORT NO. S� ❑ I, ° of he property, a e.<maivelr cony«rasa With licensed —r contractors to construct \ase Project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS. who builds or improves Nenon, and who contracts for such projects with e contractor(s)licensed pursuant t0 the Contractor's License Law. ❑ I em ...mot under Sac. ,B.&P.C.for this resents APPLICATION DATEI VALUATION PERMIT FEE Owher Date WORKERS'COMPENSATION DECLARATION Building I hereby affirm that I have a certificate OI consent to sell insure,or a car �1IIgLLI�k iifica\e of Workers'Compen...ion Inns rano,or a certified copy thereof(Sec. I%� l h ry n I I�)O Seismic 3800.Lab. / V , 5, /_ s— n /7� v Igr I L L Policy ab 'C mpeny C ffP,CP N`� �Ca Nese copy n hereby furnished. Total � Q-Certified cOV� V wi,1h,h Pec[ion division. Applicantpp A sus CERTIFIWf XE TON FR M WORKERS' N D O PERMIT AUTHORIZATION DATE COMPENSATION INSURANCE (This section nNtl not be Completed it the permit is for one hundred dol let$IS100)Or last.) 72gvYG I certify that in the performance of the work for which this permit is iI tosued I Nell Ot en 10 nY Pen=n Ina Y m§ryler so as Ionia subject the W i ;f .\ion Lem of C.1uo�gTe. C.i 0e. �N7JJ fvtiG(w- Dau Applicant I /'0�A !�V/ NOTI E O AP LICANT: 11, atb,makWg ITT., C., I aro of E emo olin, You should become subject m the Workers' Compensation provisions of the Labor Code, you must forthwith comply With such provisions or this permit All roofs shall be inspected prior to any roofing material being .netI be destined revoked. I certify mss I have read this application and state that the above inform° Installed. If a roof is Installed without first obtaining an lion is correct, I agree to comply With all city and county Ordinances and Inspection,I agree to remol a all new materials for inspection. state laws relating to building construction, and hereby authorize reprefor, is fives this city[O enter upon the eDOVlmePllONInspectInspectiond property for Inspection p �(,, 1 FTSJI - _ ✓ /� purposes.s. (We) agave .vs, indemnify s and keep es whi h the City of Cupertino against liabilities.Cti cense ue Certs and e.sting which may in any wry accrue against said City in conuquen<s of me granting or this Permit SIGNATURE OFPP ICANT PRE-INSPECTION: PLYWOOD: IN-PROGRE�1Sy 1�p� INSP. DATE INSP. DATE INSP. �t,T 25 DATN TEAR OFF INSPECTION: BATTENS: FINAL- GI I) Ur UUrL111I1._ INSP. DATE INSP. DATE INSP- DATE - NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY