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R-4606 APPLICATION FOR CITY OF CUPERTINO NUMB PERMIT 460 6 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 2`3rr l'7 LJ�j RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA ' YES ❑ If yes—I understand that a Class A NAME roof assembly is required. Q NO Initial LO.B.O.# ADDRESS � G EXISTING ROOF COVERING NUMBER OF EXISTING COVERINGS PHONE CONTRACTOR'S NAME \'�..IJRL�I v` J$�1 TO BE REMOVED_ TO BE RETAINED ADDRESS l 1 t �y.� PE OF ROOF COVERING GITY&ZIP EXISTING PHONE // �1 7)t't.` t-+,cLcr BUILT-UP ROOF ❑ CENSE NUMBER 77 ASPHALTSHINGLES ❑ LICENSED CONTRACTORS DECLARATION hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES 7000)of Division 3 0l the Business and Professions Code,and my license Is in lull force and effect. WOOD SHINGLES ❑ License Class Cis 3� Us.Number Z.,1o7 Ca Data 9—Z6 '�� Contractor rC AUd OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractor's 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 • applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's License Lew(Chapter B(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 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).): WOOD SHAKES ❑ I,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure Is not Intended or offered for Sale(Sec.7044,Business and Prefes. slons 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 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) ❑ not 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 ProfessionsCode: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 Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B 8 P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION ereby affirm under penalty of perjury one of the following declaration: I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building eS provltlad for by Section 3700 of the Labor Code,for the performance of the work for which this nu pe it Is Issued. e;g vx �— Seismic )La have and will the performance Worker's Compensation Insurance,as required by Section 3700 0l ( p ih Labor Code,for the performance of the work for which this permit is Issued.My Worker's Total Compensation Insurance carrier Poyli�cy number art: r,In P Carrierll�( E-r W^"N Policy No. Ja�-9 ``/�"L P� UTHORIZATION DATE CERTIFICATE EXEMPTION FROM WORKERS' COMPENSATION ON INSURANCE NCO (Tots faction need not be completed If Ii the the permit is for one hundred dollars($100)or less.) I certify 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 become subject t he workers Compensation Laws of car- All roofs shall-be inspected prior to any roofing material being forme. installed. If a roof is installed without first obtaining an DataP 1' Applicv�� inspection,I agree to remove all new materials for inspection. NOTICE TO PLICANT: If,after maki s Cart" a of Exemption,you should become Applicant understands and will comply with all non point subject to the Workers'Compensation pro vlsi s e Labor Code,you must forthwith comply with such provisions or this permit shall be deemed revoked. Source regulations., 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 state laws rotating to building construction,and All roof CO Ting obe class"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for in- spectlonpurposes. (We)agree to save,Indemnity and keep harmless the City of Cupertino against Ilabilities, 7� judgments,costs and expenses which may in any way accrue against said City In consequence r/ E OF-AFFFTLICANT 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 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4006 REROOF PERMIT - INSPECTION DIVISION PERMIT EXPIRATION (408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR IN DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS [!�� BUILDING USE 2t✓vJ 0015 " 4/0 + RESIDENTIAL 2� COMMERCIAL OTHER OWNER'S ,/.� NAME �Vt C' L 15" 0"1 IL FIREARDOUS COVOERING__A AREA CLASS ADDRESS z+( x(04— 'Dos V,4165 CT EXISTING ROOF COVERING 6 PHONE44 - 96 P5 NUMBER OF EXISTING COVERINGS i CONTRACTOR'S ✓u� NAME T 1.0U� 6L.jli!L- �; \ �v TO BE REMOVED TO BE RETAINED TYPE OF ROOF COVERING ADD ITYeESSS6 r7 0e) /VLI,4 '!Jr Sir � '�' EXISTING PHONE 293- 9S l 9 BUILT-UP ROOF LICENSEO U /.8,Z_ ASPH SHINGLES NUMBER W D SHAKES LICENSED CONTRACTORS DECLARATION I hereby affirm tb..I am licensed untlar provisions of Cli 9 Icommao- any with Section 70001 of Division 3 of the Susi,es. d Prpleaded.Code, ODD SHINGLES end my license is j 1 for..and.Rete 6/ [— License .. {. LicNumper 1(J OTHER (SPECIE Date Contractor OWNER-BUILDER DECLARATION I hereby win affirm mat I . exempt ream the Contract.,'. Llcema Lew for PROPOSED the following which req (sec. )Orli, Business and Professions i pr Code'. Any city ,. county wnkn r.euiior a permit to e,also re sibs,improve, demolisuch repair env snumura,prior to m issuance,also.a9ulr..the applicant for such 6 T-UP F permit 10 file a signed statement that he a licensed pursuant to the provisions Of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code)or that he is exempt there' A SH I LSE from and the basis for me anaged exemption. Any violation of Section 7031.6 by any eppli ant fora permit subjects me applicant to a civil panahy of hot more that five hundred dollars($500).1: WOO d S KES ❑ I,as owner of the property,c my employ...with wages as their sole compensation,ww do ma work, and me structure i.not intended or of1..ed OOD$H INGLE$ for sale (sec. ]044, Bwiness entl Professions Code: The Contractor's Licema Low does not apply toe =f 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 OTHE ECIFY) building or improvement is sold within one year of completion, the on builder will have the burden of proving that he did not build or improve for purpose of sale')' PROVIDE I.C.B.O. REPORT NO. C] I. a of me property, a exclusively contracting with licensed contractors to construct the project (Sec. 0044, Business and Professions Code: The Contractor's License Low does not apply to an owner of Property PROVIDE Ill INSTALLATION SPECS. who builds or improves theraun, and who contracts for such projects with a contractor(a)licansed pursuant to the Contractor's License Lew. ❑ ,e.a P.c.tats this r.. n lam exempt uncle. sec. APPLICATION DATE VALUATION PERMIT FEE Owner Data— WORKER ata P I D WORKERS'COMPENSATION DECLARATION �l Building I hereby affirm [he[ 1 have a Certificate of consent t seltinsure,or a ser. A UO l tifiu[e OI Workers'Compensation Insurance, t d copy thereof(seC. `I/ Seismic 3800, Lab.C. Q ry / o Policy No. �,- ompanv �� �� PR - 1995 BCartili.d copy n hereby furnished. Total Certit iad copv is tiled with the;city inspection division. Applicant CITi` I I t I CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. C O PERMIT AUTHORIZATION DATE COMPENSATION INSURANCE (Thissection need not be completed if [M1e permit is for one hundred dol Ian($($1000)o.lass.( \� I certify that in the peri.. of tis work for whim this permit it V F iffuaq I $nen not employ any Lebon in my manner ep as to become subject To the Workarperson i Compensation Lows of California Date Applicant 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 All roofs shall beinspected prior to any roofing material being mall be deemed revoked. I certify that l have read this application and slate that the above informs Installed If a roof Is Installed without first obtaining an tion is correct. I agree to comply with all city and county ordinances and Inspact'bn,I gree to re ove all new materiels for inspection .tate laws relating to building construction, and hereby aucborixa repb..h' ntives of this city to enter upon the above.mentioned property for inspection )/ pur (We) W. aprse to wve, indemnify and keep harmless he City of Cupertino against liabilities,judgments,costs and expanses which may In any way acmes against laid City in con..buence of me granting of oris permit. ATURE OF APPLICANT DATE 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