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R 4021 PERMIT 4021 APPLICATION FOR CITY OF CUPERTINO NUMBER R- REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (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 �\ \` �f BUILDING USE Z7 — OWNER'S .'VQl`TV\ J RESIDENTIAL COMMERCIAL OTHER e��y _1 4A. \\ Q NAME�_'I M4 4A.0,A A . FIRE HAZARDOUS COVERING ARELASS A ADDRESS ©8$Q No rillPn t 4V4' EXISTING ROOF COVERING PHONE ;if.5-L �„ 3t ci NUMBER OF EXISTING COVERINGS CONTRACTOR'S SaT �O� si] cx��MG /� TO BE REMOVED TO BE RETAINED NAME �A TYPE OF ROOF COVERING CITY&ZIP �. 7}k 73+. � t /64 2- EXISTING PHONE 97/ BUILT-UP ROOF LICENSEi/ �Q f ASPHALT SHINGLES 4L NUMBER WOOD SHAKES �f LICENSED CONTRACTORS DECLARATION 0 I hereby affirm that 1 em licensed under provision.of Chad,.,B Icommeo- clnp with Section Toon) of Division 3 of the Business and Profmion$Code, WOOD SHINGLES and my,license 1.IP rul {{pp��n and effect. 14 D.. Clns `- 7 Lia Number ID OTHER (SPECIFY) Date b� Contractor NER BUII empt f om the RATION o I hereby lowin real that I . exempt from the Contractor's LicensCode: Lew for PROPOSED L the following noon. iSec. permit, o construct.n t antl Profr.cions Codd Any city or eoumy which reouim a permit to , Io albs. Improve,and far uch repass any strfile a Sign prior to its issuance,he I aero requires the epplicem for such BUILT-UP ROOF permit to fila t.r's Li statemeense Low the,he Is licensed encauant it he tion 7 00) V of the Contractor's License Law (Chapter 8 (commencing with Section]000) ` of Division 3 of the Business and Profession.Cod.)or that he Is exempt there ASPHALT SHINGLES V from and the basis for the alleged exemption. Any violation of Section 7031.8 by any applicant for a permit subjects the applicant to a civil penalty of not more that five hundred dollen(55001.): 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 WOOD SHINGLES for sale (Sec. 7044, Business and Professions Coda: The Contractor's License Lew don not apply t0 an owner of property who builds or improves thereon, Q and who don such work himself or through his own employees,provided that lr such Improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY) ,,k 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 purpose1, -a"a')' PROVIDE I.C.B.O. REPORT NO. ❑ I, es owner of the property, aexclusively, 70 , contracting with licensed contractors to c nalruct the project (Sec )044, Business and Professions Code: The Contractor's License Law does not apply to on owner of property PROVIDE MFGR. INSTALLATION SPECS. who builds or improves theraun, and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. Cl I am exempt antler sea ,B.sP.c.for tn1. ,..an APPLICATION DATE VALUATION PERMIT FEE Owner Data WORKERS'COMPENSATION DECLARATION ® hereby .(firm that 1 have a certificate of convent to eelfinw re,or a cos - Buildln tificeae of Workers'Compensation Insurance,or a certified copy thereof Is fl// Seismic 3800, No.' / �C //IP1�t Y 11 199§ LID, �- 3800 of fa 7/ Company_^�9�r' c7�a'� 9c+y eCeaifi.d copy i.hereby furnished. Yv/ Total Certified copy is filed with the city inspection division. kr Applicant Uf CERTIFICATE E EXEMPTION FROM WORKERS' N C ❑ AUTHORIZATION DATE 14. COMPENSATION completed ON INSURANCE (Thp )or on .) not be completed if the permit is for one hundred doer Ian(ft00)or I.e.) i I ' I shall that in pllo pony rm person of any work for as to this eesubj is 1 to the I alker not employ ion Person In eery manner an n to become subject 1` to the WgrYnri Compensation Lem of Celilornia. Data Applicant NOTICE TO APPLICANT: o altar making this Compensation p of Eons pilon, You should become me subject i ms comply Workers'h such peetion provision of the Lobos node, you muss forthwith comply with such provisions or this permit All roofs shall be Inspected prior roofing material being shell be deemed rwoketl. � P P Y g g Icalcify mer I have read this application and Mate that the move informs installed. If a roof is Installed without first obtaining an non I. correct. I agree to comply with all city and county ordinances and insp err I agree to remove all new materials for inspection. stab lam relating to building construction, and hereby auth o rib nprnam rpof this cimpropertyer City to eas upon the above mtionatl property r InspectInspectionption purpose, purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs and ex Pan..which mey In any weY accrue against said city in comeguence of the granting of this permit. S NATURE 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