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R 4760 PERMIT R_ 476 Ll APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED ' WITHIN DAYS PERMIT ISSUANCE OR WI DAYSS FROM LAST CALLED INSPECTION. BUILDING ADDRESS p 0 13 /3 6 Z, /� RESIDENTIAL COMMERCIAL OTHER OWNER'S / / HAZARDOUS FIRE AREA NAME , L GY/ t.. �.,,/^ VES ❑ If yes-I understand that a Class A !—/"`/ 9 NO roof assembly is required. ,., A ❑ Initial LGB.O.x ADDRESS 13—h.4 ,�I EXISTING ROOF COVERING PHONE '7 I.�—G 7 2 .- 7 9"141 NUMBER OF EXISTING COVERINGS , CONTRACTOR'S NAME �� - � �� 7-.' TO BE REMOVED ! TO BE RETAINED ADDRESS / TYPE OF ROOF COVERING CITY&ZIP /bSAO $..7�~ ff sn • 9Si/Z . t� EXISTING ' PHONE G '�LyL 76 `7/Y BUILT-UP ROOF LICENSE NUMBER ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES ❑ 7000)of Division 3 01 the Business and Professions Code,and my license Is In full force and affect. WOOD SHINGLES ❑ License ClanC `-� / Llc.Number y Z y3 7 Z Dare 41�5��/ Contractor OWNER-BUILDER OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractor's License Law for the Mllowing reason. (Sec.7031.5,Business and Professions do: Any city or county which requires a permit to construct,alter,Improve,demolish,or rep r ny structure,prior to its Issuance,also requires the BUILT-UP ROOF 19 applicant for such permit to file a signed at Ment that he Is licensed pursuant to the provisions • of the Contractors License Lew(Chapter ( dmmencing with Section 7000)of Division 3 of the Business and Professions Code)or Ih6f i exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑ exemption.Any violation of Sectiorl �dpplicant for a permit subjects the applicant to e civil penalty of not mQ[e.iheniNa oared call re I55a0),I; WOOD SHAKES ❑1,as her of th;a1a .or e` y with wages as their Bole compensation,will do ❑ Me work,antl IhA struot Int t. leretl for sale(Sec.7044,Bualnaee and Proles- sionsCode:The.fonte - ass not apply to an owner of property who bulltla or WOOD SHINGLES ❑ Improves thereon ntl rk himself or through his own employees,provided that such lmproveme 'ard d or offered for sale.It,however,the building or improvement Is sold within one yearstlon,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ not build or Improve for purpose of sale.). U E]1,as owner of the property,am exclusivelycontracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. 7 / apply to an owner of property who builds or Improves thereon,and who contracts for such projects /p'. / with a c m exempt licensed S pursuant m Ma Comractore License Law. PROVIDE MFGR. INSTALLATION SPECS. ❑I em exempt under So. ,B 8 P.C.for this reason Owner oats WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: ❑1 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 g permit is Issued. 4//�� I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of F)v SBISmIC 9 in Labor Code,for the performance of the work for which this permit Is Issued.My Worker's / Compensation Insurance carrier and Policy number are: Total �S Carrier ffi e J5y 4 Policy No.517- 9rV5-V_ PERMITAUTHORIZAT DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.Q G (This section need not be completed If the permit Is for one hundred dollars($100)or less.) I cetlfy,that In the performance of the work for which this permit Is issued,I shall not employ any person In any manner so as to became subject to the Workers'Compensation Laws of Cell. All roofs shall be inspected prior to any roofing material being fornia, installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. NOT subject 2theOWorrkerss'Compensatlon provisionis ofetheiflLaborr Code,yolu nm, ustufothwiitthbcomply Applicant understands and will comply with all non point with such provisions or this permit shall be deemed revoked. source regulations. I certify that I have reed this application and state that the above Information Is correct.I agree to comply with all city and county ordinances and stele laws relating to building construction,and All tonV- ud,monle, atings t0 a class["C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for in. ep(We) purposes. (We)agree to index expenses and keep harmless the City of Cupertino against liabilities,an__ d, coats and expenses white may In any way accrue against said City in consequence SIGNATURE OF ICA� O or the granting of this permit. DATE- PRE-INSPECTION: PLYWOOD: -IN-PROI V,GRESS:1 I I IroV 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