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R-3647 PERMIT R_ 364 7 APPLICATION FOR CIN OF CUPERTINO NUMBER REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408)252-4505 EXT. 228 WIPERMIT EXPIRES IF ED THIN IN DAYS OF PERM RK IS T ISSUAN CNOT E 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS BUILDING USE RESIDENTIAL COMMERCIAL OTHER OWNER'SHAZ f^w ' 3 fir ' �1^v"1 /'N� AROOU ROOF NAME FIRE $ �., COVVERING AREA CLASS 0� m EXISTING ROOF COVERING ADDRESS {� (� q/)�y/� , PHONE -' Qhs b NUMBER OF EXISTING COVERINGS CONTRAC R'S1 II NAME �1' iiiB 1f1 TO BE REMovETYP OF ROOF COVERINGADDRE D CITY&ZIP D16 r 0li� OAl °(� EXISTING PHONE��S) rLJ - �1 BUILT-UP ROOF LICENSE /., �f ASPHALT SHINGLES NUMBER 111 v WOOD SHAKES eel ni, LICENSED CONTRACTORS DECLARATION T Iip I hereby •flirm that 1 em licensed under provisions of Chapter 9(comma m 1 I I g ing with Section 7000) of Division 3 of the Business and Professions Coda, WOOD SHINGLES and my license is In full force end affect. License Cie. Lic.Number Data Contractor OTHER (SPECIFY) ��g pp A OWNER-BUILDER DECLARATION If" I D I heseby affirm that I am exempt from the Contractor's License Lew for PROPOSED the following reason. (Sec. 7031.5, Business and Profession Code: Any city .1 county Which .squires a permit to construct,alter, improve, demoli•h,pr ��/y�R 2 5 1997F [/y1 repair any structure, prior t0 in inuanca also requires the applicant for such BUILT-UP R VAF permit to lila a signed steNmam the,he is licensed pursuant to the provisions ofane Contractors License Lew (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Projections Code)or that he is exempt mere ASPHALT SHIP dLESUh'Lh I INf 1 • from and ma basis for ma alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects me applicant t0 a civil penalty of not more that five hundred dollars( 50OH: WOOD SHAKES ❑ 1,as owner of the property, or my employees with wages as their sole compensation,Will do the work, and the structure is not intended or offered for Nle (Sac. 7044, Business and Professions Code: The Connector's License WOOD SHINGLES 14 Lew dose not apply to an owner of through who busied. improves thereon, and who dose such work himself or inro art his own ills or imp provides that such improvements are not intended or offered for sale, It, however, the OTHER (SPECIFY) c building or improyement is sold within one year of completion, the owner builder will have the burden of proving that he did not build or improve for Purposaofcsle.l. PROVIDE I.C.B.O. REPORT NO. D 1, as owner of In. property, em axclufively contracting with licensed connectors to construct the project (Sac. 7044, Business and Professions Coda: TheContracto:s License Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS. .no builds or improves marwn, and who Contract{IOr such projects with e connecmrl8Iicanse0 pursuant to the Contractor's License Lew. 0 1 am exempt under Sec. ,B.&P.C.for this reason APPLICATION DATE VALUATION PERMIT FEE Owner Data WORKERS'COMPENSATION DECLARATION 4o Building I hereby affirm that I neve a certificate of consent to..If naure,o tificete of Workers Compamnicn Insurance,or a certified copy thereof(Sec. /j,�, $@IsmIC 3800.Lab.C.). L Policy No: Company I BCertified top,is hereby furnished. I ` i Total -Certified Copy is filed with the city inspection division, Applicant' -% " . ,, I- � — _i? CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. ERMIT AUTHORIZATION DATE COMPENSATION INSURANCE (Trait )cu Ia nNtl not be completed if ma permit it jOr on.hundred 001 lar{($1UDf cuIan) .. I certify, thea-in the li fay erson of the work for .1which this permit is issued, L{Ihall.not emplOY�a(ty, prison in any mePnar 10 a{t0 become subject to the Wgrkeri Compensation Laws of California. Date -;Applicant^ NOTICE .TO APPLICANT: .If, after making this Certificate of Exemption, you should bactnM aublect %o the Workers Compensation provisions of the Labor Code.%du must.lorthbwijn comply with such provisions or this permit All roofs shall be inspected prlortoany roofing material being *Fall be deemed Tevdlied.. . ii, this 1 n...read his application and it.,.In.,In.above inform.- Installed If a roof Is Inst led Without first obtainingkin. tion is corracL, I agree-to comply with all city and county ordinances ane Inspection,I re8 t0 fen10V new material f rinapect nota s of this atity to building cdhe above sen, end herebyPr sutbofi r s presem .leas ws'nit city to Muer upon ins afro ion. and property for impaction purposes. (We) agr. to s indemnity and keep harmless the City of Cupertino against liabilities, judgments,costs and expenses which may In any way accrue .Wins%%aid City in consequence of me granting of this permit. SIGN OF APPL A 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 AD ItEROOI IMG POLICY FOR '1111; al Y. .01r CU)',GI�TINO 'DUILpING,uL'l An7MGNT SUUJEC'I. PRIOR'I'0 ISSUANCI..OF PI;RMI'I' ANb INSI'f:C'flOtJ 1'II�SG. I. Prior to permit issuance, you nnist agice to cortgtly.tviIICU1BiC, slntldards atid.ptanuPaelruere spec's oil mool-ilig. illspectign tell lst 2. poin 'll orbo Idin�ii slall pcclorol be A flied iilispckfoii.nlnd aPP�oOaISshill be oblaincdt fronil the,buiiii, ag,. inspcclor when the iaooGng'is eomPICICd. 1. All lypcs or root sh;tll be ilispcctcrl prior to any toof being iuslnlled. . 4. In older to teccive a limn, you,nn1sl.Coll,plcte steps I, 2„and 1. I,) Ptcinspcclion or lcacpfi'appioval:: 2.p 'Lrprogress insjwclion nPptgyah 1.) l incl inspcc1lon approval: Opcm.ilc'siiiokcdetector rciificaliat • b.) : Sim ilrancstor.ilista IIill'on 5. If plywood is installal, a'pipvood nail inspection is,rcquiml. (,,' JC :aty rode is"alrplicd withotil,fusl obtaining :m inspcclion, you will be required to remove all new ntalcri;il doq•n to the sheathing and a building inspcclor trill inspccl allshcalhing al Ilial linre. WE UNDL•RS`GAND'Tlll AUOVr; POLICY ON REIt0OFING AND WILL COMPLY WITII TILL POLICY` IIOMI:UWNERS.NAMI;: t QCEA`B A})DRESS: : Rfi11001- G COMPANY NAML: l� APPLICAN'PS SIGNA'I'URI CI'T'Y.Olt CUI!LsRI'INO UUILDING DEPARTMENT • Rct oof/tvi n tvoi d