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R 62260 0 OFFICE COPY PERMIT R_ 6 2 2 6 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (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 c—;2.22757— RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA C YES ❑ If yes — I understand that a Class A NAME .7�Q� roof assembly Is required. NO ❑ Initial I.C.B.O. # - c ^�-- �1 ROOF COVERING ADDRESS NUMBER OF EXISTING COVERINGS / QEXISTING r PHONE / CONTRACTOR'S NAME / � � / TO BE REMOVED TO BE RETAINED ADDRESS�?L�G/J�� /a /L TYPE OF ROOF COVERING CITY 8 ZIP /Gyp/G- EXISTING /073 7' T 7 7a7C� PHONE ❑ BUILT-UP ROOFLICENSE NUMBER t�x7�eT ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provisions of Chapter S (commencing with Section WOOD SHAKES Lam' 7000) of Division 3 of the Business and Profs to Cod entl my license Is In lull force and effect, �]�7/^/' WOOD SHINGLES ❑ Ulcers Cja� Lie. Number `� OTHER (SPECIFY) Date Coin OWNER. ILDERDECLARATIONI hereby affirm that I am exempt from the Contractor's License Law for the following reason, 7031.5, Business and Professions Code: Any city or county which requires a toLl� F(Sec. ILII permit or repair any structure, prior to Its Issuance, also requires the tconstruct,alter,Improve,demolish, OOF I applicant for such permit to Elie a signed statement that he le licensed pursuant to the prcvlalons1n,�,Tr,�t of the Contractor's License Law (Chapter B (commandop with Section 7000) of Division 3 of thehIIWLi end Professions Cotle) or that he le exempt therefrom antl the basis for the alleged I pyBusiness JASPH l3ti J 1998exem tion. An violation of Section 7031.5 p y dyanys($5ant lora prmit aublecfe the eppllceni toa civil ponelty of not more Than five huntlretl ticllare ($500).1:❑I, KES as owner of the property, or my employees with wages as their sole compensation, will do the work, antl the structure le not Intended or offered for sale (Sec. 7044, Business and Profenalone Cotle: The Contractors Ucense Law tloee not apply to en owner of property who builds or Improves thereon, and who does such work himself or through his 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 -builds, will have the burden of proving that he did OTHER (SPECIFY) ��%0✓l �'� not bull or Improve for purpose of sale.). ❑ I, as owner of the property, em exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Lew does not p a Q 9J 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 Contractors License Lew. ❑ 1 am exempt under Sec. a 8 P. C. for this reason PROVIDE MFGR. INSTALLATION SPECS. Owner Dale 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 Concent to self -insure for Workers Compensation, for by Section 3700 of the Labor Code, for the for /, �// BUfldln g � performance of the work which this pe mit Is Is permit la Issued. 9 �� .� // pp ❑ have and will maintain Worker's Compensation Insurance, as requl red by Section 3700 of $eISn11C the Labor Code, for the performance f the wa for which this permit Is Issued, My Worker's Compee ca r e Ilcy '7 "� Total ` 2—Ae 8 c n or are: A �� PERMIT AUTHORI N DATE Cefz rrle Pallcy iT CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.O (This section need not be completed If the perm) for ono hundretl delta re ($100) or lase.) I certify that In the performance of the wokform,s permit le ued, shall not employany person In a manner ace ee to become sorkers'"°m ansatlon Lawn, of call All roofs shall be inspected prior to any roofing material being rarnla. �b Finstalled. If a roof is installed without first obtaining an Date / Applies�L�^�-�— inspection, I agree to remove all new materials for inspection. after subject to thNOTICE e orrk rs'Compefnsation provisions ofthe,tlLabor Code, cate of Exemption, mustufothwlltlhbecome omply Applicant understands and will comply with all non point with such provisions or this permit shetl be deemed revoked. source ulations. I' certify that l have read this application and state that the above Information is correct. l agree to complywith o and county of ces and to building construction, and All r f verings to class "C" or better. hereby authorize ze rcityep this herebyyn purposes, ie representatives of ihle city ice enter upon the above mentlaned property for In. to ter upon the on aee. (We) agree to save, indemnify and keep harmless the City of Cupertino against Ilebllltle9, judgments, costa and expenses which may in any way accrue against said City In nst liabilities, uence /© /�� NATURE OF APPLICANT 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 OFFICE COPY