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99100043 s6, z � o aoo PERMIT _ APPLICATION FOR CITY OF CUPERTINO NUMBER R 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 ADDRESS , 8 74 . BRAN y- RESIDENTIAL COMMERCIAL OTHER OWNER'S /.,,, .,,/p / /' - HAZARDOUSFIRE AREA. 'NAME �z `--"'z S n Ir-rPP'(-� YES Ifassemhly sunderstand requthat a Class A • / �j/// f/�' /� NO ❑ Initial I.C.B.O.q _ ADDRESS /�` 8 .HbdU!/ - la,. - , " EXISTING ROOF COVERING PHONE . NUMBER OF EXISTING COVERINGS CONTRACTOR'S_ ' NAME vU r ' -�`C 1'� �J TO BE REMOVED TO BE RETAINED - ADDRESS , TYPE OF ROOF COVERING CITY&ZIP / 8 ,5 Z 'EXISTING 'PHONE --7Z3 /. BUILT-UP ROOF El NUMBER " C� moi" Z 6-'Q 8 ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION hereby affirm that I emcenunder provisions a (c ci i KE S 7000)of Division 3 of the Business antl Professions C lic effect. • All ' 15 GAINGLES License Class - (] - �- Lic.Number (SPECIFY) © . Date - "Contractor - !`~ OWNER-BUILDER DECLARA I P Ep I hereby affirm that I am exempt from the Contractors Lie aw or the allowing reason. (Sec.7031.5,Business and Professions Cotle: Any ci or cou r a rmi U construct,alter,improve,demolish,or repair any structu o t esF oar "�' 1999 applicant for such permit to file a signed statement that [tot is n of the Contractors License Law(Chapter 9(commencln o I� Business and Professions Code)or that he is exempt ref ba a gad ASPHALT SHINGLES exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than fivehuntlretl dollars($500).): ' El 1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES BY the work,antl the structure is not intended or offered for sale(Sec.7044,Business and Profes- sions Code.The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES _ improves thereon,and who does such work himself or through his own employees,provided that ❑ such improvements are not intended or offered for said.If,however,the building or Improvement is sold within one year of completion,the owner-builder will have the burden of proving that he did' SPECIFY OTHER not build or improve for purpose of sale.). (SPECIFY) - ❑ - - E]1,as owner f the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE LC.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 Contractor's License Law. ❑ PROVIDE MFGR.INSTALLATION SPECS. P 'I am exempt under Sec. ,B&P.C.for this reason Owner Date ATIO APPLICATION DATE ALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATIONS ' 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 Worker's Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 3 g permit is issued. S Seismic 1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued.My Worker's l O Compensation Insurance carrier and Policy number are: _ Total �.z, Carder - Policy No. PERMIT AUTHORIZATION DATE fit' CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C. (This section need not be completed COMPENSATION permit is for one hundred dollars($100)or less.) ' 1 certify that in the performance of the work for which this permit is issued,I shall not employ r any person in any manner so as to became subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being forma. - / installed. If a roof is installed without first obtaining an Data Approa�@ 9 - `r inspection,I agree to remove all new materials for inspection. "NOTICE TO APPLICANT: If,atter meld dg this rtificate of Exe prion,y a and become Applicant understands and will comply with all non Dint subject to the Workers'Compensation prov ions the Labor Cotle,you mu hwith comply' pp p y p with such provisions or this permit shall be d revoked. - source regulations. I certify that I have read this application and state that the above information is correct.)agree .to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class Zebr better. ?< hereby authorize representatives of this city toenter upon the above-mentioned property for in- spection purposes. (We)agree to save,indemnity and keep harmless the City of Cupertino against Ilabilines, judgments,costs and expenses which may in any way accrue against said Coy in consequence DATE of the granting of this permit. SIG ATU OF APP UANVO PRE-INSPECTION:. r 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