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R 4933• n FFtr.F rl PERMIT R_ NUMBER 4 9 3 3 APPLICATION FOR CITY OF CUPERTINO INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408) 777-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 100 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION, BUILDING ADDRESS �_ `�'re✓� 1 V �:-J RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA ( YES ❑ If yes - I understand that a Class A NAMEV `p v-,,, roof essemtyy is required. NO Initial I.C.B.O. K EXISTING ROOF COVERING ADDRESS- IS ��� �,l PHONE S5- 7cI7 NUMBER OF EXISTING C VERINGS CONTRACT 'S NAME �^ OQ l 1'� TO BE REMOVED TO BE RETAINED ADDRESS C�'7� �� ���� TYPE OF ROOF COVERING CITY & ZIP�j3!!� is PI EXISTING —// PHONE r 19 BUILT-UP ROOF ❑ NUMBER tom© nL— ASPHALT SHINGLES LICENSED 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 Coda, and my license Is In full force and ) effect. _ �(^ � ` �N0 a� ItP WOOD SHINGLES S/ ❑ License Claes ` Luc. Number `'-' . el -(( "r1 � In OTHER (SPECIFY) ❑ Data Contractor —F46� OWNER -BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractors License Law for the following reason. (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter,Improve,demolish, or repair any structure, prior to Its Issuance, also requires the BUILT-UP ROOF El for Such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's License Law (Chapter 0 (commencing with Section 7000) of Division 3 of the Business Professions , and Code) or that he Is exempt therefrom and the basis for the alleged 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 live hundred dollars 1$500).): C]1, as owner of the property, or my employees with wages as their sola will do WOOD SHAKES ❑ compensation, the work, and the structure Is not Intended or offered for Sale (Sec. 7044, Business and Profes- alone Code: The Contractor's License Law does not apply to an owner of property who builds or Improves thereon, does himself his WOOD SHINGLES ❑ and who such work or through own employees, provided that such Improvements are not Intended or offered for sale. 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 OTHER (SPECIFY) E3not build or Improve for purpose of sale.). ❑ I, as owner of 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 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 contractor(s) licensed pursuant to the Contractor's License Lew. ❑ I em axe under Sec. ,B 6 P. C. for ihla reason PROVIDE MFGR. INSTALLATION SPECS_ . O nSir— Date (fig 21 Ill WORKER'S COM V' ATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one f the following declaration: ❑ I have and will maintain a Certificate of Concent to self -insure for Worker Worker's Compensation, rr� ,p `Y f A 1r� as provided for by Section 3700 of the Labor Code, for the performance of the work for which this Building permit lave and ❑ have and will maintain Worker's Compensation Insurance, 1 JUN Seismic ' Z2 as required by Section 3700 of ,the Labor Code, for the performance of the work for which this permit Is iasuetl. My Workers 1 O 19Q /� 15(_ CompensaJ`Iq\rLnsur ncecer end Poli numberare: [y' ^ ( �" _l V Cliff r v Total PERMITIAUTHORIZATION DATE Carrier (�A+-t�- Policy No. CERTIFICATE OF EXEMPTION FROM WORKERS' 6 COMPENSATION INSURANCE N.C. (This section need not be completed If the permit IS for one hundred dollars (8100) or lase.) V (iQl/H� I certify that In the performance of the work for which this permit is issued, I Shall not employ All roofs shall be inspected prior to any roofing mate ri b any person In any manner so as to become subject to the Workers' Compensation Lawe of Call- forma. installed. If a roof is installed without first obtaining an Date Applicant inspection, I agree to remove all new materials for inspection. Ilcant understands and will comply with all non point P P Y p NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shot. be doomed revoked. SO gulations. I certify that 1 have read this application and state 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 CIas or better. hereby authorize representatives of this city to enter upon the above-mentioned property for in. cpecllon purposes. f (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may In any way accrue against said Cly In consequence I I SIGNAT REOFAPPLICAN DATE of the granting 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 n FFtr.F rl