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R-5097 PERMIT R_ 5097 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 2 g RESIDENTIAL COMMERCIAL OTHER owNER's HAZARDOUS FIRE AREA TTYES ❑ If yes—I understand that a Class A NAME � _ ,1.IL & !Sq�/0 x p�/ roof assembly is required. NO ❑ Initial I.C.B.O.,R ADDRESS QQYYI ° EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS / CONTRACTOR'S TO BE REMOVED TO BE RETAINED NAME ADDRESS TYPE OF ROOF COVERING clTv&ZIP95037 EXISTING —c•� PHONE' DSl'p',3S$—/�33 BUILT-UP ROOF - ❑ - NUMBER 7 ASPHALT SHINGLES ❑ LICE ED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES .7000)of Division 3 of the Business and Professions Code, d my license Is In full force and effect. WOOD SHINGLES License Class 139 Llc.Number •9� �� ❑ O ❑ Date Contractor OTHER(SPECIFY) OWNER-BUILDER DECLARATION PROPOSED 2 hereby affirm that am exempt from the Contractor's or coca Law for the following reason. / (Sec.construct, It Business and Professions Code: Any city or county which requires a permit to l q construct,alter,Improve,demolish,or d statement any structure,Is Icao its issuance,also requires the BUILT-UP ROOF ❑ applicant for such permit to flaw a signed statement that g Ish Section pursuant to the provisionsofthe o the Contractor's scans Lew(Chapter 9(commencing with Sactlon 7000)of for the 3 0l the �l exemption, and Professions Code)or that he is exempt therefrom and the base for the ica nt to ASPHALT SHINGLES ❑ asemppen.Any violation of Section hundred by any s($ 0 applicant for a permit subjects the applicant to e civil penalty of not more than five by employees yellers(h wag): WOOD SHAKES ❑ ❑I,as owner of the property,or to employees with wages as their Bola compensation,will s- the work,and the Contractor's Is not Intended ores not for sale(Sea owner of Business entl Protea- sons Code:The,a n who does such Lew does not apply to an owner of property who bulltls or WOOD SHINGLES ❑ Improves thereon,entl who does such work himself or through his own employees,Improvement provided that such Improvements are not Intended or offered for sale.If,however,the building or Improvement ii Is sold within one year of completion,the owner-builder wl 11 hove the burden of proving that he did OTHER(SPECIFY) Aa.ma 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. -352-3 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. ❑I am exempt under Sec. ,B&P.C.for this reason Owner nate 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 self-Insure for Worker's Compensation, �^ n p ^ Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 1'_ /+ D /So permit is issued. 1 Seismic ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of pnn�aa 0 d the Labor Code,for the performance of the work for which this permit Is issued.My Workers rysA�/ / Total 8r�� Compensat n Insuranc carrier and Policy number are: ��) Q ..IIA r Carrier _ Policy No.✓✓99//1•� 2 S PERMITTIf TH_ORIZATION DATE fCERTIFI ATE OF EXEMPTION FROM WORKERS' 't COMPENSATION INSURANCE N.O� A vi CrlIDVU (This section need not be completed If the permit Is for one hundred dollars($100)or less.) P —T--O xJ 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 Cell- All roof^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. subject lo ltot eWo erss'Compensation proviafter sions of theCertificate Laborr Code,Exemption, musuforthwithbecome comply Applicant understands and will comply with all non point with such provisions or this permit shii 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 relating to building construction,and All roof coverings to be class"C"or better. hereby authorli representatives of this city to anter upon the above-mentioned property for In- spection purposes. `_y ce y�7 (We)agree to save, Indemnify and keep harmless the City of Cupertino against liabilities, -'L. �/ ! / judgments,costs and expenses which may In any way accrue against said City In consequence SI&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 —�� PERMIT R_ 5097 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 2 g RESIDENTIAL COMMERCIAL OTHER owNER's HAZARDOUS FIRE AREA TTYES ❑ If yes—I understand that a Class A NAME � _ ,1.IL & !Sq�/0 x p�/ roof assembly is required. NO ❑ Initial I.C.B.O.,R ADDRESS QQYYI ° EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS / CONTRACTOR'S TO BE REMOVED TO BE RETAINED NAME ADDRESS TYPE OF ROOF COVERING clTv&ZIP95037 EXISTING —c•� PHONE' DSl'p',3S$—/�33 BUILT-UP ROOF - ❑ - NUMBER 7 ASPHALT SHINGLES ❑ LICE ED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES .7000)of Division 3 of the Business and Professions Code, d my license Is In full force and effect. WOOD SHINGLES License Class 139 Llc.Number •9� �� ❑ O ❑ Date Contractor OTHER(SPECIFY) OWNER-BUILDER DECLARATION PROPOSED 2 hereby affirm that am exempt from the Contractor's or coca Law for the following reason. / (Sec.construct, It Business and Professions Code: Any city or county which requires a permit to l q construct,alter,Improve,demolish,or d statement any structure,Is Icao its issuance,also requires the BUILT-UP ROOF ❑ applicant for such permit to flaw a signed statement that g Ish Section pursuant to the provisionsofthe o the Contractor's scans Lew(Chapter 9(commencing with Sactlon 7000)of for the 3 0l the �l exemption, and Professions Code)or that he is exempt therefrom and the base for the ica nt to ASPHALT SHINGLES ❑ asemppen.Any violation of Section hundred by any s($ 0 applicant for a permit subjects the applicant to e civil penalty of not more than five by employees yellers(h wag): WOOD SHAKES ❑ ❑I,as owner of the property,or to employees with wages as their Bola compensation,will s- the work,and the Contractor's Is not Intended ores not for sale(Sea owner of Business entl Protea- sons Code:The,a n who does such Lew does not apply to an owner of property who bulltls or WOOD SHINGLES ❑ Improves thereon,entl who does such work himself or through his own employees,Improvement provided that such Improvements are not Intended or offered for sale.If,however,the building or Improvement ii Is sold within one year of completion,the owner-builder wl 11 hove the burden of proving that he did OTHER(SPECIFY) Aa.ma 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. -352-3 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. ❑I am exempt under Sec. ,B&P.C.for this reason Owner nate 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 self-Insure for Worker's Compensation, �^ n p ^ Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 1'_ /+ D /So permit is issued. 1 Seismic ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of pnn�aa 0 d the Labor Code,for the performance of the work for which this permit Is issued.My Workers rysA�/ / Total 8r�� Compensat n Insuranc carrier and Policy number are: ��) Q ..IIA r Carrier _ Policy No.✓✓99//1•� 2 S PERMITTIf TH_ORIZATION DATE fCERTIFI ATE OF EXEMPTION FROM WORKERS' 't COMPENSATION INSURANCE N.O� A vi CrlIDVU (This section need not be completed If the permit Is for one hundred dollars($100)or less.) P —T--O xJ 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 Cell- All roof^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. subject lo ltot eWo erss'Compensation proviafter sions of theCertificate Laborr Code,Exemption, musuforthwithbecome comply Applicant understands and will comply with all non point with such provisions or this permit shii 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 relating to building construction,and All roof coverings to be class"C"or better. hereby authorli representatives of this city to anter upon the above-mentioned property for In- spection purposes. `_y ce y�7 (We)agree to save, Indemnify and keep harmless the City of Cupertino against liabilities, -'L. �/ ! / judgments,costs and expenses which may In any way accrue against said City In consequence SI&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 —��