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R 4108 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4108 REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408) 252-4505 EXT. 228 WITHIN EXPIRESRMIT 80 S OF IF PERMIRK T ISNOT SUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS BUILDING USE RESIDENTIAL COMMERCIAL OTHER OWNER'S G HAZARDOUS ROOF NAME / '4 �� / eL- FIRE COVERING AREA CLASS ADDRESS ��7�� EXISTING ROOF COVERING PHONE r NUMBER OF EXISTING COVERINGS CONTRACTOR'S 17 // NAME !/v�ISS �(/ TO BE REMOVED TO BE RETAINED TYPE OF ROOF COVERING RESS CITY&ZIP r/✓�/ G /�—llliG� EXISTING PHONE 019 BUILT-UP ROOF LICENSE -� / ASPHALT SHINGLE NUMBER Y WOOD SHAKES L I CENSED CONTRACTORS DECLARATION Y hereby affirm that I am licensee under provisions of Chapter (commm WOOD SHINGLES cin with Section 7000) of Divl,ion 0 of the Business and PI.Issions Code, and my Ilcmm le in ldfl for d effect. ��y7^ �Jp/ anLicensey Ctess tic.Number y� / J b pater f Connector OTHER (SPECIFY) Sys OWNER-BU140ER DECLARATION �j I hereby affirm that I am e.ampt from the Contractors License Law for PROPOSED the following reason. (Sec, 7001.6, Business and Profession.Code: Any city or county which requiem a permit to construct,alter, improve, demalish,or rmair any structure.Prior to in issuance, also require,the applicant for suchgUl BUILT-UP ROOF permit to fila a signed statement that he I.licensee pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) 3a ��v • from Division 9 of the Business th entl Proalleged exem tion. or that he is n .1 S hese ASPHALT SHINGLES cJ nom ane the basis test the and Pro camp tion. Any violation 01 Section 7091.6 by any applicant for a permit subject, the applicant to a civil penalty of not mora that five hu noted dollars($600).1: WOOD SHAKES EDI,as Owner Of the Property.or my employees with wag..as their sola compensation,will do the work,and the structure is not Intended or offeree for sea (Sac. 7044, Business end Professions Coda: The Contractors License WOOD SHINGLES Law apes not apply tp an owner Of properly who build.or improves thereon, ) and who don such work himself or through his own employees,provided that such Improvements ora not intended or offered for sale, If, however, the OTHER (SPECIFYY. 6T buildr "�'•f�!!ing or improvement is sold within one year Of completion, the owner butler will have the burden of proving that he die not build Or improve for g purpose 1 est.own PROVIDE I.1��,0 RE Ft7�0� ❑ I, as Owner of ha property, em exclusively contracting with licensed , 33'' contractor. to construct the project (Sec, 7044, Business and Professions Coda: TheContrantor'. License Law does not apply to so owner of property PROVIDE MFGR. INI°i*KATION SPECS. who builds Or improves thereon, and who contracts for such Projects with a c°mnctorn)licensee pursuant to the Contractor's License Law. /N ma❑n 1 am exempt under Sec. ,B.&P.C.for this APPLICATION DATE VALUATION PERMIT FEE ,..On Data WORKERS'COMPENSATION DECLARATION Building 1 hereby affirm that I have a cartificatekof consent to nlf i'sure,0r Is car ^ G / eificaa Laob. Workers'Compensation Insurance,or a certified copy thereof(Sac, w Seismic 9800, b.C.I. T I / Policy NO. Company / M Q d t O o BCartiflad eoPY I.hereby furnislorl. L/ V Total Certified copy is filed with the city inspection division. Applicant CERTIFICATE OFI SATION NSUFROM RANCE WORKERS' N.C. 0 PERMIT AUTHORIZATION DATE COMPEThis section need not be completed i6 the permit is for One huntlrad opt I...($100)Or Ion.) I certify that In the performance of the work for which This Permit i. issued, I shall not employ any person in any manner W as to become subject 10 the Workers Compensation Laws of California. Data Applicant NOTICE TO APPLICANT: If, after making this,Cortificaxa of Exemption, you should become subject 10 the WOrkete'-ComyeneatiOn provisions Of the Labor Code, you must forthwith comply with such provisions or his permit All oofa shall belna inspected prior an roofing material bei' mall be doomed revoked. P P Y g g I certify that I hwa read this application and nate that he above informa led. if a roof IS Installed without first obtaining an tion i. correct. 1 agree to comply with all city and county ordinance,and i tl n,I tee to r e ell n materials rinS B nate laws fNuing to building construction, and hereby euthorice to ratan. P g P P CtlOn. tally.,of this city to enter upon the above mentioned Property for inspection pulp°..,. ' (We) agr.. to save, indemnify and keep harmless the City o1 Cupertino against liabilities,judgments,core and expanses which may in any way accrue against mid Clty in consequence Of the granting of this Permit. SIGNATU E'OF APPLICANT DATE PRE-INSPECTION: PLYWOOD: IN-PROGRESS: INSP. DATE INSP. DATE INSP. DATE TEAR OFF INSPECTION: BATTENS: i FINAL' INSP. DATE INSP. DATE INSP. " DATE NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY