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R-3919 APPLICATION FOR PERMIT R_ 3 919 CITY OF CUPERTINO NUMBER - cwNSPECTIONDIVIS1ON PERMIT EXPIRATION REROOF PERMIT (408)252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS BUILDING USE I—IRESIDENTIAL V COMMERCIAL OTHER OWNER'S^ /l HAZARDOUS ROOF NAME FIRE COVERING AREA CLASS ADDRESS SC,)4C25 EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S 2 k TO BE REMOVED TO BE RETAINED NAME 1 ,C J_7n��e- TYPE OF ROOF COVERING ADD&Zsa?,O . \Y EXISTING PHONE 1) BUILT-UP;/HIN LICENSE 51© ASPHALTLES NUMBER —,_W- SH SH LICENSED CONTRACTORS DECLARATION ^y� I hereby affirm that I am licensed under provisions of Chaptar B(co 'v n\- l\ cin, with Section 70001 of Division 3 of the Business and Profenbm Code, WOOD S ES/ and my licmx is W e end effect. C Licanx C Li<.Numbs. y'� Dasa ^ — Dd..[neto 0 H ( P IF ) J OWNER-BUILDER DECLARATION is \ 11 I hereby affirm that I am exempt from ,he Contractors Lici Law for P P D „ I D me following reason. (Sec. 7031.5, Business and Professions Coda: Any city or county which requires a permit to c nstruct, alter, improve,demolish.., far=any structure.prior to its issuancei else sed pus ua t to them for such B L P ROOF F perM[to fila a signed statement that he t licensed pursuant to the Provisions E JL �a-j� of the Contractors License Law (Chapter 9 (commencing with Section 7000) Jv7y) • of Division 3 01 the Business and Professions Codel a,met he is examp,th..." ASP LT SHI LES h ' from and the basis for Ns alleged exemption. Any violation Of Section �ylJ�• 7031.5 by any applkmT for a permit ubiecn the applicant to a civil penalty lir ���Cfildly of not more he,five hundred dollars($5om.1: WOOD SHAKES V D 1,as owner of ma property, or my employees with wages as their sole compensation,will do the work, and the structure is not Intended or offered WOOD SHINGLES for sale (Sec. 7044, Business end Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, pp and who does such work himself Or through his own employees,provided that I n \\ /•L ^�� ucb improvement are not intended or offered for sale. If, however, the OTHER (SPECIFY) boiltli ng or ihip,... an[ is sola within one year of completion, the owner builder will have the burden of p,Oving[h., he did no,build or improvefor _ Purposeof sale.). PROVIDE I.C.B.O. REPORT NO. D 1, as owner of ma property, am exclusively contracting with licensed contra tars to construct the project (Sec. 7044, Business and Professions Coda: The Contractor's License Law does not apply toanowner OfProperty PROVIDE MFGR. INSTALLATION SPECS. who builds or improves thereon, and who contracts for such projects with a contactors)licensed pursuant to the Contractor's License Law. On 1 am e.ampt under Sec, ,B.&P,C,for this lee APPLICATION DATE VALUATION PERMIT FEE Owreal Data WORKERS'COMPENSATION DECLARATION Building .VV 1 hereby affirm that I nava a certificate of consent to self ins I car ufkete o1 Workari Compensation Insurance,or n.1.Lcopy •eraof(Sac. 7 �yS� B� $eISR11C 1qQ 3800,I,ebtf..y_„a� np \_ .L. / Pool ic o. `Jj�.JL.>• ` Company C.�� 1�t1 .L• L C.rbfied copy I$hereby furnished. Total Q,�jfi.d�c pyIBjt�j`e ,v inl�ct+nn division. ADDIIUOI CERTIFICATE OF EXENDSFTION FR ORKERS' N.C. ❑ PERMIT AUTHORIZATION DATE COMPENSATION INSURANCE (This section need not be completed if In.permit is for one hundred dol Are($100)or less.) I certify that in the performance of the work for which this permit i issued, I shall not employ any parson in any manner so as to become subjac, to the WOlk.,�Compensation Laws of California,n Data Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should second. subject to the Work.,, Compensation provisions of the Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. All roofs shell be inspected prior toany roofing material being l .."if, that 1 have read this application and state that the above informs. Installed. If a roof Is Installed without first obtaining an tion is cor`e t. I agree to co ply with all city and county ordinances and inspection,I agree to remove eW materialsfor inspection. state laws relating to building construction. and hereby authorise repradem tativx of this city to enter upon the above-mentioned property for inspection purposes. r\ p` 1. (Wel apse to save, indemnify and m tl keep harmless e City of Cupar — \ exinat liabilities,judgments,costs and expenses which may in any way---% .wine[said City in consequence of the granting of in..permit. SIGNATURE OF APPI 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