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R-4161 (2) PERMIT R_ 4161 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION, BUILDING ADDRESS / BUILDING USE /O d. 2 L , RESIDENTIAL COMMERCIAL OTHER OWNER'S 9HAZC iQa��7 y!/E•J✓,J G - ROOF NAME C i E'P iC FIRE ARDOUS COVERING AREA "V CLASS ADDRESS /O 0A En. � s'04 fee. EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S TO BE REMOVED TO BE RETAINED NAME r,Tv 11612 , el�l TYPE OF ROOF COVERING CIITY a ZIP r�� ( ae4„✓� �L. « al! 9d FISTING PHONE l2/.�l gpo BUILT-UP ROOF LICENSE ASPHALT SHINGLES NUMBER WOOD SHAKES L CENSED CO TRACTORS DECLARATION WithhereS affirm that I of ived.. under provisions of Gtepto 9(comment cing with a tion 7000) of Division 3 of the Business and Proleulons cods, WOOD SHINGLES and my li<mee ie In full fo c ane effect License Clm�7 /� Lin.Number -- Dole—�� Ay cony«tor OTHER (SPECIFY) / OWNER BUILDER'ECL I ne.ebv anirm met am exempt rrvm the cont. ,. Llcen aw for PROPOSED the following reason. (Sec. 7031.6, Business and Professions Coda: Any city or county which nauire. a permit to construct, offer, Improve,dimi repair any structure,prior to iu issuance,also requires me applicant for such BUILT-UP ROOF Permit 10 file a signed stand tn.t ase i.lin.nsed pursuant to the provisions of the Contractors License Lm (Chapter 9 (commencing with Section 7000) from Division 3 of the Badness and alleged exem tion. or rhes he is exempt S mase ASPHALT SHINGLES C of D and the bases for the alleged esions Cod Any violation of taction 7031.6 by any applicant for a permit subjects the applicant to a civil penalty of not more that flys hundred dollen($600).1: WOOD SHAKES ❑ f,s owner of me property, or my employes,with wages as their sola com Pensation,win do the work, and the structure is not intended or offeree WOOD SHINGLES for. I (Sec. 7044, Business and Professions Code: The Contractor's License Law don 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 Improvements are not intended or offend for sale. It, however, the OTHER (SPECIFY) building or improvement is sold within one year of completion, the owner builder will have the burden of proving that he did not build or improve for Purpose as PROVIDE I.C.B.O. REPORT NO. ❑ I, s owner of the property. em exclusively contracting with fiunsed contrec fors to construct the project (Sec. 7044, Business and Projections Code: The Conn«tar'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 protocol with e contractor(I Iicenud pursuant to the Contractor's License Lew. O 1 em exempt under Sec. ,B.&P.C.for this reason APPLICATION DATE VALUATION PERMIT FEE Owner Dau WORKERS'COMPENSATION DECLARATION Building I hereby affirm tn., I have a certificate of consent to sell.insure,or a car [iliuta of Workers QQQQCpoomppensation Insurance,or ancertified copy thereof sec. O f� Seismic \ 3800.Lab.Cl._ •Vf X995 Policy No.tfyC Og//(�/ pony Total Corti ' d copy is nareb lurnis e . certified copy est '� itY inspec 'on d.varal C0 t- VI ito Applicant T EM FROM WORKERS' PEI AUTHORIZATION DATE COM SATID SU RANCE N.C.0 (This section need not be completed if the permit is for one hundred dol I...($1001 or Istel ��/],��j(I��, artily Lost n me pertormen[eot the work which rases permit I. vV- •` s� issued, I shell not employ any person in me r ea to become object L/ to the WON C ensatlon Lew.o o Pete ATpliun NOTIL T P L CANT: 11,lirflIFF, rinfibloll Will Corti ase of Exemption, you should bacons. obi«t to the Workers Comp. tion Dr0.4ions of the Labor Coda, you mot forthwith comply with such provisions or thisthispe.mit .hall domed revoked. All roofsshall be Inspected priortoany roofing material being I unifv that I hove read this application and state that the above Inmrma. Installed. If a roof Is installed without first obtaining an lion is torr«t, l agree to comply with au city and county ordinances and inspectio agree to remove all new materielsforinspectlon nate laws relating to building construction, and hereby author:[. represent naves of this city to enter upon the above mentioned Property for inspection pct rooses. IWe) spree to live, indemnify and keep harmless M• City of Cupertino against liabilities,judgmenn,costs and expenses which may In env way accrue DATE 1% against said City in conwouen<s of the granting or this permit. SI T OF LIOANT 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