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R 3808 (2) PERMIT APPLICATION FOR CITY OF CUPERTINO NUMB R Res 3808 REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK 15 NOT STARTED WITH N IBO DAYS OF PERMIT ISSUANCE OR ML 190 DAYS FROM LAST CALLED INSPECTION. IV BUILDING ADDRESS Irn� C Q BUILDING USE IO �r 1/y'1ldtjQ � RESIDENTIALCOMMERCIAL OTHER OWNER'S HAZARDOUS ROOF NAME I „„ (/n1 1�� ��y� p /� p AREA CIRE LASS COVERING ADDRESS` Lo i� W7,I/`-�`7u^ �'-"— 111a�� EXISTING ROOF COVERJING PHONE 7�/� _ 4 NUMBER OF EXISTING COVERINGS J CONTRACTOR'S_ �� ,,��77 NAME f?pt ,�lry- /)�I,/1 Pae_., 6//XY_,�" TO BE REMOVED TO BE RETAINED I ��! 1 (.�� '��C/1 ' TYPE OF ROOF COVERING CDOv&is6 fyl' Co , EXISTING PHONE 3&Q-744 O BUILT-UP ROOF LICENSE / Lf p'f„ ASPHALT SHINGLES NUMBER LP lJ ll1 �— WOOD SHAKES LICENSED CONTRACTORS DECLARATION hereby Section that I am Domed under provblonn of chapter 9 ons(..rhri Code WOOD SHINGLES cine with Section 70001.�0yelf Division 3 Of Me Bulinus ntl Professions Code and my license is I l e and effect. LI=•ns•L{a-N Contractor OTHER (SPECIFY) Let• �1 o Lie.Number OWNER BUILDER DECLARATION I hereby affirm that I em exempt from the Contractor's License Lew for PROPOSED the fpllowi..anon. (Sec. ]031.5, Business and Professions Code: Any city or county which requlras • Permit to construct. alter,improve, demOliM,or label any Structure,Prior to Its Issuance,also requires the applicant for such BUILT-UP ROOF pomh to fib a signed statement that he is licensed pursuant to the provisions of the Contractor. License Lew (Chapter 9 (commencing with Section 7000j OI Division 3 of the Business and Profeuions Code)or that he is exempt Mere. ASPHALT SHINGLES from and the basis for the alleged exemption. Any violation of Section ]031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more that five hundred dollen($600).1: WOOD SHAKES ❑ I,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 sale (Sec. 701 Business and Professions Code: The Contractor's License WOOD SHINGLES Lew don not such to an owner of property who buildsorImproves provided tht and who deo such work himself or property his own employee, oves thereon,tont such improv.ments are not intended of offered for .ale. n, however, the OTHER (SPECIFY) building of 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 O� porooas a.goPROVIDE I.C.B.O. REPORT NO. ❑ 1, s owner of the property, em exclusively contraction with licenesd contractors to construct the project Ise=. 7044,app Business and Pr property whoCodTIdshe Contractor's hic•ma and who cot tract.for anesuch pr ofocts with a PROVIDE MFGR. INSTALLATION SPECS. who l improves meson, end who contncU for such projects with a contract.,(.)amexempt undo, Se to the ComremorY Liuma Law. reason I em exam Dt untlar So. ,B.&P.C.for this Own., oats APPLICATION DATE VALUATION PERMII FEE WORKERS'COMPENSATION DECLARATION BUlldin I h...by affirm that I have a certificate of consent to ulhimure,or a car. - tificet•of Workers'Compensation Imes n o{a c•yy1+f�Intl�topy thereat ISec. - . 3900,Lab.1b176�4Ec ��''y'Jluy j Salami Policy \ Policy No. ompanv �GR.L © 1 ` 44 Certitletl COPY is hereby IurniM•tl. 'co `` � Total Cardflad o 1' it the ty i iv Senn. s AP Ilont ,.\� CRT ,t� FICATE O EMPTION FROM WORKERS' 1 �( tIPERMIT AUTHOR( ATION DATE COMPE TION INSURANCE N.C. ❑ (This sec need not be completed if the permit is for one hundred dol. Ian($100)or less.) 1 carni, that in the perform...• of the work for Which this permit is inuad, I shall not employ any parson In any manner so.s to become subject to the IN Compensation Lew,of California. Date Applicant NOTICE TO APPLICANT: If, alto making this Certificate of Exemption, You Mould become subject to the Worker: Compensation provisions of the Labor Coda, you mart forthwith comply with such provisions or this permit All roofs shall be Inspected riortoan roofing material bei. Mall be tleemyo res asst f p p y g g I certify that I have read this application and state th.,the above Informs. Installed. If a roof Is installed without first obtaining an tion Is course'. I agree to comply with all city and county Ordinances and stats lawe relating to building construction, and hereby authorise r•pfe,an. Inspection,I agree to remove all new materiels for inspection. tativas of this city to enter upon the abovb-mentioned property for Inspset10 purpose. (We) sane tq are, indemnify and keep harmless the City of Cupertino against liabilities,judgment.,costs and expense which may In any way se=rue against said Clty in consequence of the granting of this Permit. sI NATUR OF APPLICANT DATE V 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