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R-3853 APPLICATION FOR PERMIT 3853 CITY OF CUPERTINO NUMBERR— INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMI T�SUAN CE 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS ,,� � 1 BUILDING USE Z L-G/,LV iF171 I , RESIDENTIAL COMMERCIAL OTHER OWNER'S ROOF NAME o vtl l, �." FIREAR HAZARDOUS r� 1 COVERING AREA �,/ CLASS ADDRESS I�S�2- {'L'I • EXISTING ROOF COVERING ZA is NUMBER OF EXISTING COVERINGS PHONE CONTRACTOR'S (� NAME Ai'U` S Ik-S -Di�i,..4 I-VtQ TO BE REMOVED TO BE RETAINED O TYPE OF ROOF COVERING COYRESS &Zs IITa 33� rhC..l.Cw �w A1oSG EXISTING PHONE I —4455' BUILT-UP ROOF LICENSE ASPHALT SHINGLES NUMBER 513OD WOOD SHAKES LI CENSED CONTRACTORS DECLARATION I hereby affirm that I am licen.ed under provisions e,1 Chapter 9(comment ung with Section]000) of Divi.ion a o1 In.Business and Prof..aone Code, WOOD SHINGLES and my license 1.In u0 f ,< end effect. 5 Licante Clan Lic.Number D.\. con\rector OTHER (SPECIFY) WNER BUILDER DECLARATION I homy affirm that I am exempt from the Contractor's License Law lar PROPOSED the following reason. (Be . )0]1.6, Business and Profession.Code: Any city Countyor which requires a permit to c nstruct, alter, Improve,demolim,Or repair any structure, prior to its issuance,also requires the applicant for Such BUILT-UP ROOF Permit to file a signed statement that he is licensed pursuant to the provisions w� M f a1 the Contractor's License Lew (Chapter 9 (commencing with Section]000) of Division 0 of the Business and Professions Code)or that he is exempt there. ASPHALT SHINGLES L 4 from end the basis for the alleged exemption. Any violation of Section —� )OJ1.B by any applicant for a permit subjects the applicant to a civil penalty of not mon that live hundred dollen($600).): WOOD SHAKES ❑ 1,as owner of the propanv, o my emplayan with wags.a.their Bola comp.n..\ion,will do the work, and the structure is not intended or offered WOOD SHINGLES for 7" (Sec. ]046, Business and Professions Cade: The Contractor's License 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 improvemen[. a no\ intended a offered for sale. If, however, the OTHER (SPECIFY) building or improvement c nt is sold within one year of c mpletion, the o builder will have the burden of Proving that he did not build or improve for purpose ofIale.)' PROVIDE I.C.B.O. REPORT NO. ❑ 1. as owner of the property, a exclusively contracting with licensed ontrac tar: to construct the project ( ec. )044, Businessand Profession. Coda: The Contractor's License Law does not apply to m owner of property PROVIDE MFGR. INSTALLATION SPECS. who builds o improves thereon,and who contracts for such projects with e contractors)licensed pursuant to the Convector's License Law. ❑ 1 am exempt under Sec. ,B.&P.C.for this D.t. APPLICATION DATE VALUATION PERMITFU ow WORKERS'COMPENSATION DECLARATION Building 1 hereby affirm that I have a certificate of consent to Belt insure,or a car lificata e,1 Workers'Compensation Insurance,or a certified copy thereof Isec. {.� ]800.Lab CA ,��.,,,, � ! Pf J�(i 42) $eI3mID Policy NO.Pc.N4opy is Company�~?W�tsZ'_. `Jp� covE.d cony is hereby b,mi.P.d. /j•� Total Cerlil'ad copy is fi;��T••''th the city inspection division. APplican[ see- — '.__ CI CE RTI FICA OO'F�EXEM ION FROM WORKERS' N.C.C ❑ V,- PER TAUTHORIZATION DATE COMPENSATION INSURANCE Uf 1 (Thi.section head not be completed if the Permit is for one hundred dol Jan. Is 100)ar I. ) Cr 1 f f/vim IS I certify that in the Performance of the work lar wnich this Permit is issued. I shell not employ any person in any manner so as to become subject t0 the Work., Compensation Laws Of California. Det. Applicant Ac NOTICE TO APPLICANT: If, alter making this Certificate of Exemption, you should become subject to the Workers Compensation provision. 01 he Labor code, you must forthwith comply with such provisions or this permit All roofs shall be inspected prlorto any roofing materiel being .hall be deemed revoked. I Certify that 1 have read his application and at.,.In., he move inlo,m. Installed If a roof is installed without first obtaining an \ion if torr..,. I spree to comply with all city and county ordinances and Inspection,I agree to remove all new materialsforinspection state lam relating to building construction, and hereby authorise represent native,of Ilii.city to enter upon the above mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of CupertinoO .gain.\ liabilities.judgments,costs and expense.which may in any way accrue ��-A-'"t""--' 14 in., ✓` � /` �/`��'� rosin.t said City in can reou.M..of the gnntlng ere this oermi\. SIGNATURE OF APPr6T V D TE 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