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R 4036 OMBERROORMIT APPLICATION FOR CITY of CUPERTINO '4036 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT PERMIT EXPIRES IF WORK IS NOT STARTED (408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR ISO DAYS FROM LAST CALLED INSPECTION. \ BUILDING ADD ✓ yJ(/�DRESS c ILDING USE \� ! U 5 1 V'o J e_c_,+ e RESIDENTIAL COMMERCIAL OTHER Ik OWNER'S t n YV �_ COVERING Vv��V �� HAZARDOUS C) CLASS tt� ROOF NAME FIRE P crJ ADDRESS_�S o J f� EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS ! CONTRACTOR'S n S� .1'Q. � /�-(_J TO BE REMOVED TO BE RETAINED NAME TYPE OF ROOF COVERING ADDRESS CITY&ZIP EXISTING BUILT-UP ROOF A A a _ PHONE_ *' LICE NUMBERNSE ASPHALTSHINIGG19 LICENSED CONTRACTORS DECLARATION WOOD SHAKES!U!- UurC�1l1Y� I hereby offirm the,1 am licensed under provisirn%of Chepl. 9(common cin. with Section 7000) of Division 3 of the Business end Professions Coda, WOOD SHINGLES and my license if �u race end effect. A Dan = Contractor 2 OTHER (SPECIFY) Dm Contractor OWNER-BUILDER DECLARATION I hereby affirm. that I am exempt from the Contractor s License LOW for PROPOSED the following reason. (Sec. 7031.8, Business and Professions Code: Any city or county which requires • 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 fila a the Business enmant that ha is licensee ou hath to exe provisions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) _1 fr m,and 3 of the forthand Proalleged exam tion. or that he d•adopt them ASPHALT SHINGLES 7031 end the basis for the allermi exemption. Any ant to o1 Sec Non 7031.8 by any that hu fora pomp subjacn ma applicant[o°civil penalty 01 not mon twee five hundred artier($500).):em WOOD SHAKES p ❑ I,ti owner of the property. Or he employees with wends of Noir area \v-\ for 9 1*(Sec. will e0 me work, and ess structure h not intended '.ollena yy00D SHINGLES for sees(Sac. 7044, Business and PrProperty o arty who The r nvecmi s License Lew does not apply o an owner of hr o through who buildslo imp!oras merehat and who does antuch work no, intelf or ed or offered hie own r Sol . If, howevetl son such ngorr impros are not old wits or neyfor cola. If, hOthevo, the OTHER (SPECIFY) builder. or improvement is at within one year of complete or ma owner builder will have the burden of Dr Ovim.hot he tlitl not build or improve for purpose era down PROVIDE I.C.B.O. REPORT N0. ❑ I. owner of the property, exclusively contracting with licensed cdnVecton to construct the gooiest (Sac. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS. who build% or improves thereon, and who contracts for such Projects with a contractor(s)licensed pursuant to the Contractor's Licence Law. ❑ 1 .m exempt !neer Sac. ,e.aP.c.for this APPLICATION DATE VALUATION PERMI EE meson Owner Data t WORKERS'COMPENSATION DECLARATION Building I hereby affirm that I havee/a certificate of consent to self•inwre or a car. policy ry f Workg, O.�Pd7p nylnw!arca oL if ad 'J , pot(Sec. �S- ' ,v, / � C) S`aiemlCTZ �- 3800,Lab 1v1'orr' A[Certified copy Ia hereby furnished. T0181 II Car . Applicant CERTIFICATE EXEMPTIONFRO WORKERS' N,C, O PERMIT AUTHORIZATION DATE COM NSATION INSURANCE (This Section need not be completed if the permit i%for one hundntl tl06 �\\ �� Q�/]7� /IS /y ears 1001 or leaf.) `f 0 + C I certify that in the performance of the work for which this Darmit is issued.hI ma11 not employ any Lenon In any manner to n to become subject t0 the Worker'Compensation Laws of Celifornis. Do' Applicant NOTICE TO APPLICANT: If, sitar making this Certificate of Exemption, You Should become subject to the Workers' Compensation Provisions of the Labor Coda, you must forthwith comply with Such provisions or this permit All roofs shall be inspected prior roofer materialbein mass be deemed revoked. P P Y g g I certify the, m I have read this application end state that the above InforF Installed. If a roof Is Installed without first obtaining an tion is correct. I agree to comply with ail city and county ordinances and din a tioei I ego a 10 move all ere aterielaforinapeCtlon f.tiv.of ela laws retailing t0 building construction, and hereby authorize reprssem the%city to enter upon the above mentioned property for Inspection purposes. IWO) area to save, indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs and axpenreo which may in any way accrue SIGNATURE O PPLICANT DATE O ria City in consequence of the granting of this Permit. PRE-INSPECTION: PLYWOOD: N-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