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R 4983i® OFFICE COPY PERMIT R_ 4983 APPLICATION FOR CITY OF CUPERTINO NUMBER REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED " WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. _ BUILDING ADDRES I'7 , i( RESIDENTIAL COMMERCIAL - OTHER OWNER'S,' HAZARDOUS FIRE AREA YES ❑ If yes —1 understand that a Class A NAME '� Lir, -4194 roof assembly is required. NO Initial I.C.B.O. tl Z ADDRESS 223 G E E NUMBER OF EXISTING COVERINGS PHONE 2 © CONTRACT 'SrIN — NAME C1 m �( TO BE REMOVED TO BE RETAINED ADDRESS 2 / © �� 0-/ TYPE OF ROOF COVERING l Z CITY &ZIP 1• EXISTING ^' a PHONE BUILT-UP ROOF ElLICENSE NUMBER ca 7l ASPHALT SHINGLES ❑ L CENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter g (commencing with Section WOOD SHAKES 7000) of Division 3 of the Business and Professions Code, en my license le In lull force nd effect, —3 WOOD SHINGLES ❑ License Cleve Lic. Number - Date Corrector CS 1 O OTHER (SPECIFY) ❑ OWNER -BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason. PROPOSED (See. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, altar, Improve, demolish, or repalreny,at'cte;.rsrto Its Issuance, also requires the applicant for such permit to fila a signed statement th Pe Ilcehas pursuant to the provisions BUILT-UP ROOF ❑ of the Contractors License Law (Chapter. 8 (commenci Wllh'. ction 7000) of Divlslon 3 of the Business and Professions Code) or that he la exempt relrpm and the basis for the alleged ASPHALT SHINGLES ❑' exemption. Any violation of Sectlon7031.5 by any applic Ipr a permit subjects the applicant to a civil penalty of not more the hundretl tlo ars $5 ) I, WOOD SHAKES ❑ as owner of the pllop y, or my employe as as their sole compensation, will do the the I Inten work, and structOre not tl of or sale (Sec. 7044, Business and Profes- sions Cotle: The Contrectde LI ie t appI to an owner of property who builds or Improves WOOD SHINGLES ❑ inereon, a�M who such r himself or tnrough his own employees, provided that such Improvement Bre Oce dee .offer etl for sale. If, however, the building or Improvement -of is sold within one year mple nriheowner•builtlerwIII have the burden of proving that he did not bulltl or improve for oseo sale.). OTHER (SPECIFY) ❑ pu ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sea, 7044, Business and Professions Code: The Contractor's License Law dose not PROVIDE I.C.B.O. REPORT NO. apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractors) licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS. ❑ I am exempt under Sec. ,B 8 P. C. far this reason I Owner Date— DECLARATION WORKER'S COMPENSATION DECLARATIO APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: ❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compensation, for by Section Building as provided 3700 of the Labor Code, for the performance of the work for which this permh Is Issued. ❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of -the Labor Code, for the performance of the wor lar which this permit Is Issued. My Workers Compensation Ina ante carr tl Policy On er are: O � /1 y� (( d Seismic Total ' 11_ • r �� Carrier Policy No. 1 / Vh FERMI A HORIZATION A CERTIFICATE OF EX MPTION FROM WORKERS' ' COMPENSATION INSURANCE N.C.O _h y1 (This section need not be completed if the permit Is for one hundred dollars ($100) or teas.)I certify that in the performance of the work for which this permit Is Issued, I shall not employ All roots she beInspected priortolany roofing m erial being any person In any manner so as to become subject to the Workers' Compensation Laws of Cell- forma. installed. If a roof is installed without first obtaining an Date Applicant inspection, I agree to remove all new materials for inspection. subject to the WoTICE TO rker ' Compeneelion provPLICANT. If, after isions of the11cate of Laborr Code, Exemption, mustuforthwith lcecome comply Applicant understands and will comply with all non point with such previsions or this permit shalfbe deemed revoked. Source regulations. I certify that I have read this application and elate that the above Information Is correct, I agree to comply with all city and county ordinances and state laws relating to building construction. and All roof Brings t0 aclass hereby authorize representatives of this city to enter upon the above-mentioned property for In -spectates purposes. (We) agree to save, indemnity and keep harmless the City of Cupertino against liabilities, ZTrbetter. coat and expenses which may in any way accrue against said City In consequence SIGNA E OF A (CANT ATE YJ ofjudgments,the gran al the renting of this permit. 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