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R-3444 (2) PERMIT R_ 3444 APPLICATION FOR CITY OF CUPERTINO NUMBER REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408) 252-4505 EXT. 228 PERMWITHIIT EXPIRES IF N IN DAYS OF PERM RK IS T NOT OR 190 DAYS FROM LAST CALLED INSPECTION. 1 BUILDING ADDRESS BUILDING USE 1 d RESIDENTIAL COMMERCIAL OTHER wNER'S .� HAZARDOUS ROOF NAME FIRE COVERING AREA CLASS ADDRESS �Q `t C ' I n I EXISTING ROOF COVERING PHONE /� NUMBER OF EXISTING COVERINGS 1� l7 v� (cs I CONTRACT 'S TO BE REMOVED NAME r/Y V__Q liD I �' TYPE OF ROOF COVERINGED CITY I�`? SD. '��� W/ �3�I EXISTING PHONE �T GBUILT-UP ROOF LICENSE /j� ` O ASPHALT SHINGLES D NUMBER e f WOOD SHAKES LICENSED CONTRACTORS DECLARATION I n.r.br 01irm that I am licensee under provi.lon.of Chapter 9 Icommem WOOD SHINGLES alms, with Section 7000) of Divi.lon 3 of ins Business and Prof assns loCode, and mV C me,Is in to Mort gd }tact. ^ License Lic.Number OTHER (SPECIFY( Dau ^ Connx.or��1 1A O NER-BUILDER OECLARA ION y 1 hereby affirm that . exempt from the Connection License Lew for PROPOSED 10 m•following r«son. (Sac. 7 exem from dna attract ons Coen: Any city - �j or county which require. a permit to construct,alter, Improve, eemolish,or repair an,.p..t.nv.prior.o I.Issu.nc.,ono..gl.w.a.n.applicant for such BUILT-UP ROOF Permit to file a sianed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing with Section 70001 of Division 3 of the eu.ineat and Prof«.ions Codol a,mat he is exempt hers ASPHALT SHINGLES from and the basis for the alleged exemption. Any violation of Section e 1176 7031.8 by any t five team re •dollars subjects the applicant to a civil penalty ' of not more that fwd nhedr,. aty, r my em WOOD SHAKES ❑ I,no owner of tat•grope,a or he employees with wages as mein sole compensation, i . (S . will dE tat•work,dna the on Code is not ontra t 's License WOOD SH INGLES for.ala (Sea 7044, talon andn., Prof«tions who The Connectors License Law when rpt.poly tL an owner of through is o n em to improves e , rov menton, and who rdoesimprovements work hlm_II or through hie own r sole, If provided that I r. 4/ / ff r/r� such ng or improv are not intended wit. or one year for ilia, t1, however o, me /OTHER.ISPECIFY) « l�/r`Q building or improvement is .old within one Year Li completion, me owner ( / builder will Few ma bureau of proving that he dltl not build or improv for purr,...of%el.,l. PROVIDE I.C.B.O. REPORT NO. ❑ I. as owner of the property,am exclusively contracting with licensee contractor' to construct the project (Sec. 7044, Business and Profession% Coda: The Contractor's License Law does not apply to an owner of property PROVIDE MFG R. INSTALLATION SPECS. wh a builds or improves thereun, and who conte""for Such projectl with e contractor(s)licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. ,8.&P.C.10,this PPLICATION DATE VALUATION PERMIT FEE Owner Data WORKERS'COMPENSATION DECLARATION Pl A ' ® __/vy ,x s.C'S Building 100, I hereby affirm that nava i tanniciran of consent to self inem•, o a car [" \!Jn//, }[% ue of Workers' Compensation Insurance ora certified cr�Y thereof(Sea Seismic 3800,Lab. j • i t .g q��p Policy NO.�e�ompeny (lT 1 I LI. Cara/ie co by fur d. APR Total 8 Cerdtietl .til , utY P non division. Applicant cI de w -Aq�—NI CERTIFICATE OF E E fiON FROM WORKERS' 1' ' THORIZATION DATE COMPENSATION INSURANCE N.C. D an: section need not be completed if the permit is for one hundred do4 Ian 191001 ornoel m I certify that in • performance of the work for which this permit is 1 issued. I .roll not employ any Parson in any manner.o as to bacome.pbjact t to the Work.,.'Compensation Lms o1 California. Data Applicant NOTICE should APPLICANT: o dinr making this Compensation p of Exemption, you ar Cole boome subject i h c mply with Compensation provisions of the .hall Code. ird must forthwith comply wins auto provisions of this permit All roofs shall be inspected prior toany rooting material being .hall be a«mea rhave. I have I certify that nee this application dna Tete that the above informaInstalled if a roof IS installed without first Obtaining an tion is correct. 1 ogee to comply with ell city and county ordinances and inspection,I agree to remove all new materials for Inspection. .,at• laws relating to building construction, end hereby authorize represem tNvn o, this city to anuli Coen m.above mentioned property for inspection Pur(We) pat ave, V ,.so * \� :n I • to • indemnify cos era keno es which the City of Cupertino agel«.ti id Cite., consequence costs and expense.wt is may in any war accrue aym.t.aid City in aonseapenae of The granting m[tri.Permit. IGNATURE OF APPLICANT DATE 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 .-