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R 6082 PERMIT 'R_ 6082 . APPLICATION FOR PITY 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 T - - 1 775- CG \ S S t -III RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA NAME /7 e VtO G�5 -e (-1 �. YES ❑ If yeas I undeassembly i reqand that, Class A ( iN roof assembly is required. NO ❑ InNal I.C.B.O.# ADDRESS pQ ` ®7t 60 6o r '��"-'Tvk'C�o�F"� _ EXISTING ROOF CO, ERINN7G PHONE O 6 9 rOs NUMBER OF EXISTING COVERINGS CONTRACTOR'S 0, _�� f� CP r TO BE REMOVED TO BE RETAINED NAME � 19' '� V(r ADDRESS (y. 'y �/ _ /f OF R O OVERIN CITY&ZIPP—k..7b S 3�j SZ 7 � S. S/ + C44 .Q PHONE ` C © O p&I T-gpo&� LICENSE I „ N NUMBER z0 ASPHALT SHINGLE ❑ LIC NSED CONTRACTORS DECLARATION hereby affirm that I am licensed under provisions of Chapter B(commencing with Section V WO El , 700 0)of Division of the Business and Professions Code,and my license Is In full force and 1 effect. _ 7 / zo 0 WOOD SHINGL S El WOOD Lic.Number Date O —� Contractor OTHER(SP ❑ OWNER-BUILDER ECLARATION 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,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 9(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).): E]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑ the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes- sions Code:The Contractors 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 El 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 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 Law. PROVIDE MFGR. INSTALLATION SPECS. ❑1 am exempt under Sec. ,B&P.C.for this reason OwnerDate WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: 9 ❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building 2 ` as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this parTiusIveuetl. b0 CJ Seismic IgTheve and will maintain Worker's Compensation Insurance,as required by Section 3700 of 4 9, t I ebur Code,for the performance of the work for which this permit is issued.My Workers Compensation Insurance cerrler end Pollcy pumber are: Total 59 Carrier STS ��'V`C!A� Policy No2(_ r7 PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.0 (This section need not be completed If the permit is for one hundred dollars($100)or less.) .^ 4 2-1-99 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 to the Workers'Compensation Laws of Cali. -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,.)agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point subject to the Workers'Compensation provisions of the Labor Coda,you must forthwith comply P Y P 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 la correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and All roof Coverings 19rbe class"C"or better. hereby authorize representatives of this City t0 enter upon the above-mentioned prOpBfry for in As // sp(We) purposes. /-/,A/ C/�j`,_.--_. (We)agree to save,Indemnify and keep harmless the Clry of Cupertino against Ilabilltles. C� [. judgments,costs and expenses which may In any way accrue against said City In consequence -SIG of the granting of this permit. IV RE OF APPLICANT DATE . PRE-INSPECTION: PLYWOOD: IN-PROGRESS: /V J INSP. DATE INSP. DATE INSP. DATE . 7 i TEAR OFF INSPECTION: G j3 BATTENS: - - FINAL: INSP. DATE I/ ` INSP. DATE INSP. DATE NOTE: OSHA'APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY