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R-4010 (2) PERMIT APPLICATION FOR ��" CITY OF CUPERTINO NUMBER R- 4 010 REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408) 252-4505 EXT>228 OT STARTED WITHIN MIT 180 DAYS OF PERMITIF WRK IS�SUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS _ `-BUILDING USE O -eCil,'V `" r RESIDENTIAL COMMERCIAL OTHER — OWNERS HAZARDOUS ROOF NAME ' `� -r `*-l��t) y ) FIRE COVERING /1 , o AREA CLASS ADORES,aalv � �� �^ EXISTING ROOF COVERING PHONE 255 NUMBER OF EXISTING COVERINGS CONTR TOR'S s TO BE REMOVED TO BE RETAINED NAME © - ITYPE OF ROOF COVERING AD CIITOY RESS&ZIP i �`--'v"r v- l EXISTING PHONE — LICENSE �q� BUILT-UP ROOF LICENSE _ ASPHALT SHINGLES NUMBER WOOD SHAKES LICENSED CONTRACTORS DECLARATION with affirm that 1 of licensedson under provisions l d 1, fi 9 Icammee ciag with Cy�{coon Too 1 of Division 3 or the epsl ns{�p�a P. rsuions coda, WOOD SHINGLES dna my Ii< nM 1�1 force is enecc y� Data•a Ac / Connactb r V OTHER (SPECIFY) OWNER-BUILDER DECLA I hereby affirm that I am..empt from the Convactoi s Lic. Lew f . PROPOSED the following reason. (Sec. 7031.5, Business and Prof en ions Code: Any City OI County which requires a permit to construct, alter, improve,eemalienO , l NA V n repair any nructure.Prior to its issuance: also requires the applicant for such BUILT-UP ROOF �� 19 . x, permit to file a signed statement that he a licensed pursuant to the provisions fGefly7� of the Contractor's License Lew (Chapter 9 (commencing with Section 7000) U/- of Division 3 of the Business and Professions Code)or that he is exempt mare ASPHALT SHINGLhi;UNEHl - from and the basis for the alleged exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of aat more that five hundred dollars 1$500).1: WOOD SHAKES ❑ I,as owner of the property, or my employees with wages as their sole com pansation, will do the work,and the structure is not intended or offered for tab(Sec. )044. Business and Professions Cade: The Contractor's License WOOD SHINGLES Law don not apply to an owner of property who builds or improves thereon, and who does wch work himself or mrough his own amployeas,providea met such improvements are not Intended or offered for sale. If, however, he OTHER (SPECIFY) building improvement is improi sole within one year of completion, the owner builder will have the burden of proving that he did not build or improve tar Inurpose of sale.). PROVIDE I.C.B.O. REPORT NO. ❑ 1, as owner of ma property,a exclusively contracting with licensed contrecton to construct the project 1Sec. 7044, Business and Professions tads: The Contractors License Law does not apply to an Owner of property PROVIDE MFGR. INSTALLATION SPECS. Who builds or ins Provas theraun, and -no contrects for such proacts with e contrachi licensed pursuant to the Contractor's License Law. ❑ lam exempt under sec. ,B.aP.c.to.anis..eon APPLICATION DATE VALUATION PERMIT FEE Owner Date WORKERS'COMPENSATION DECLARATION ✓^ Buildin I hereby affirm that I neve certificate of consent to self-insure,or a car V til00' of W .ker C�o etjgp In ,or a caaifiatl c v the.aar S.C. I / 85i $elSmiC 3800,Lab 1. "�A /1 IL 'I�`f�JIM.J`\�J Policy No. C pe y a Cacti lied copv is hone furnished. , L Tot:I .[anir fi as t t Inaction di APPlmant—yq�Te-/t�Y�^ if ` s CERTIFICATE dgEVEMPTION FROM WORKERS' PERMIT AUTHORIZATION DATE COMPENSATION INSURANCE NC• ❑ (Thissection head oat be completed if ma Permit is for one nuneree e06is Ian($100)or Ins.) ��/ certify that ,n the performance of the work for which this permit issued, 2. I shell not employ any person any manner to n to become subject to ma Workers'Compensation Laws of California. Data Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you Mould become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such Provisions or this Permit All roofs shall be inspected prior to any roofing material being Mall be deamed revoked. I certify mat I have read this application and seta mat the above informs installed. If a roof is installed without first obtaining an tion is correct- I egfea to comply With all city and county ordinances and Inspection,I agree to remove all new materials fort peCR Y state laws relating to building construction, and hereby sumoriee repredem tatives of this city to anter upon the above mentioned property for inspection pulpae... 1� (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs and expenses which may In any way accrue against said City in consequence of the granting of this permit. 911—GNIATURE OF APPLICANT DAT ' 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