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R 6199t _OFFICE COPY __ _ PERMIT R- 6199 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 100 DAYS FROM LAST CALLED INSPECTION, BUILDING ADD/REESS 002— <--Andi L Wood d%'e RESIDENTIAL COMMERCIAL OTHER OWNERS FIRE AREA QHAZARDOUS ✓� p'Ll. efCA VES ❑ If yes —1 understand that a Class A NAME v root assembly is required. NO E]Initial I.C.B.O. # //�� ,�,,,,�� // 862-C-.A'nAEVJ00d EXISTING ROOF COVERING, ADDRESS AQ. , PHONE Z S S Z 9 NUMBER OF EXISTING COVERINGS Z Z CONTRACTOR''S,, I - NAME Vv (i.�� Am s„Y raj TO BE REMOVED TO BE RETAINED , ADDRESSTYPE / Lar bifOks OF ROOF COVERING CiaZIP_-'/c3! &V!!!1 ry EXISTING PHONE BUILT-UP ROOF El LICENSE NUMBER t19'/e9q ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION hereby that em licensed antler provisions of Chapter (commencing with Section WOOD SHAKES ❑ iaffirmnion 7000) of Division 3 of the Business and Professions Code, entl my license le In lull force end y - affect. q n IF `— 7 q 7 Y ) WOOD SHINGLES EllO! License Cls a Lie. Number Z8C?ll/ OTHER (SPECIFY) ❑ Date Cotractor n ��T If OWNER -BUILDER DECLARATION hereby affirm that I am exempt from the Contractor's License Law for the following reason. PROPOSED (Sac. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, altar. Improve. demolish, or repair any Structure, prior to Its Issuance, also requires the BUILT-UP ROOF ❑ applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's License Law (Chapter a (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES u y exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): C] 1, as owner of the property, or my employees with wages a a their Sola compensation, will do WOOD SHAKES ❑ the work, and the structure is not Intended or offered for sale (Sec. 7044, Business and Pnofes- alone Coda: The Contractor's License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or through his own employees, provided that WOOD SHINGLES ❑ such Improvements are not intended or offered for sale. It, however, the building or Improvement Is sold within one year of completion, the owner -builder will have the burden at proving that he did not build or Improve for purpose of sale.). . OTHER (SPECIFY) ❑ ❑I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (See. 7044, Business and Professiana Code: The Contractors License Law does not PROVIDE I.C.B.O. REPORT NO. apply to an owner of property who bullas or Improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors License Law. E]I am exempt under Sec. ,B & P. C. for this reason PROVIDE MFGR. INSTALLATION SPECS. Owner oats WORKER'S COMPENSATION DECLARATION 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 seg -Insure for workers Compensation, /(:P-. On as provided for by Section 3700 of the Labor Code, for the performance of the work for which this Building permit Is Issued. ❑ naveve andentl will Workers Insurance, as required by Section 370001 7 / r1 �Bd Seismic CO the performance ,the Labor Code, for the p met and o/ the work for which this permit Is laeuetl. My Workers f the work Compensation Insurance carder and Policy number are: Total 1O 6n 1" fes/ 7 3� 7 PERMIT AUTHORIZATION DATE Carrier Policy No. 7'0 CERTIFICATE OF EXEMPTION FROM WORKERS' /1/v��C /�6/9'Y� COMPENSATION INSURANCE N.DID (This section need not be completed if the permit Is for one hundred dollars ($100) or leas.) 1 certify that In the for Is Issued, I .� r• /'-_• V performance of the work which This permit shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Cell. All roots Shall be inspected aing fornia. z8 3 C2Y. installed. It a roof is ins d wi first btai r an Dale Applies nt inspection, I agree to remo II ne me ials r ins( ion. NOTICE TO PPLICANT: It, 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 or this deemed revoked. Applicant understands a III`tip Ixgx It (�7a(1�Iyyrt' pN ��x�o Dint provisions permit shaorbe source regulations. V Lr I certify that I have read this application and state that the above Information is correct.I agree to comply with all city and county ordinances and slate laws relating to building construction, and All roof covering to be Cl !. S"C"Or better. hereby authorize representatives of this city to enter upon the above mentioned property for in. spection purposes. By (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, 1 judgments, costs and expenses which may In any way accrue against said City In consequence of the granting of dila permit. SIGNATURE OF APPLICANT DAT PRE -INSPECTION: PLYWOOD: IN -PROGRESS: INSP. DATE INSP.-DATE INSP.-DATE - TEAROFF INSPECTION: BATTENS: FINAL: INSP. DATE INSP.-DATE INSP. DATE NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION _OFFICE COPY __ _