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R 4831 PERMIT R_ 4831 , APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED ' WITHIN DAYS PERMIT ISSUANCE OR WI DANSS FROM LAST CALLED INSPECTION. BU�ILLDIIINNIG ADDDD/RE(S/,S.I /J `-"- `� RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA �jt•/ - YES EI It yes-I Understand that a Class A • NAME roof assembly is required. NO L Initial I.C.B.O.k ADDRESS / EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S 70 BE REMOVED 1/ TO BE RETAINED NAME ADDRESS / j `�j TYPE OF ROOF COVERING Sz cl7v&QIP L. G --7 EXISTING PHONE / �r, d 7 / BUILT-UP ROOF Cl LICENSE NUMBER 7 ASPHALT SHINGLES ❑ LICENSED CONTRALTO S DECLARATION I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect /1 _ WOOD SHINGLES ❑ C License Class Lic.Number ��-�j ❑ Date Can OTHER(SPECIFY)trector� OWNER-BUILDERD RAT PROPOSED �• f I hereby affirm that I am exempt from thriydontramor'A Is se tew for the following reason. (Sac.7031.5,Busingge and Profession bdo:-Any.citf ny wh requires a permit to construct alter,improve,demolish,or r Ir structure. or Itsusta e,also requires the BUILT-UP ROOF qR 2� e Ilcanl for such permit m lila a el n ef�I mem that'h°Is a yy puii7yysu t to the pravlelone 4pxs� ' of the Contractor's License Law(Chip IB( Gna with s IMn 1 ) I Division 3 of the Ip kJ Business and Professions Coda)of 1 SI 6e.1! t iherelro , rid the t as for the alleged ASPHALT SHINGLES r ❑ exemption.Any violation of Section/? 1 yapp ant mh j is the applicant to Lrr a civil penalty of not more than Ivd dr°dd?er ($5 ). `y ��' �t•r pyU ❑I,as owner of the props or employs, I _ rsoa ompensallon,will do WOOD SHAKES ❑ the on,and the structure Is tended or r orsa ac. 0(W;Business and Profes- alone Code:The Contractor's ans,e n ply to e0 ow ol property who builds or WOOD SHINGLES Improves thereon,and who do a rk all or thr his qqwwn employees,Provided that ❑ such Improvements are not Int lyI alteredfa sale. howeyeFvtha building or Improvement Is sold within one year of completl th pu tsawlll Ift theburden of proving that he did OTHER(SPECIFY) ❑ r not build or Improve ler purpose of setel).`._� ❑I,eeowner of the property,aman Professions Code: ng Twithntracetls Licentorstoconstruct the project(Sec, ofPrperty Business hand PronasionsCode:TheandwhoconrctsfoLaw does not PROVIDE LC.B.O.REPORT NO. 473 apply to c ntownerof property who pursuant or Improves thereon,and who contracts for such protects with) coniexem(t)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS. ❑I em exempt antler Sec, ,B 8 P.C.for this reason - owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: 111/1 ❑1 have and will maintain a Certllicat°of Consent to self-insure for Worker's Compensation, Building as provided or by Section 3700 of the Labor Code,for the performance at the work for which this y permit is Issuedvend. �{�OD r Q seismic ❑ have and will the pert Workerrmanc'e Compensation Insurance,hth'a as required su d.My 3700 0l 3' -9 / d the Leber Coda,for the performance of the work I which this permit le Issued.My WorkeYe Carrier n Insu n terrier an olicy numb ere: Total Cerner Policy G/ PERMITAUTHO ON DATE l CERTIFICATE E%EMPTION FROM WORKERS' COM NSATION INSURANCE N.C.I] (This section need not be completed If the permi-ti for one hundred dollars($100)or less.) I certify that in the performance o1 the work whic%tthis permit Is Issued, ll not employ any person In any manner so as to become tact t n Wo ny Compen L s all. All r .,shall a Inspected prior to any r ofing me rial g lornla. installed. If a roof is installed without first obtaining an Dale Appliaan inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making this C I to of Exemption,you should become q I' understands and will Comply with all non ant subject to the Workars'Compensation provislons 11 Labor Code,you must forthwith comply pP P y P with such provisions or this permft ehalGbe deem volved. so Ce re lations. I certify that l have read this application and a that the some information Is correct.)agree to hereby authorize cityrep and county ordinances to ser upon the bove- eating d property f and Il roof co Brings to Ia C"otter. hereby authorize representatives of than city a enter upon the sing to builds above-mentioned preparty for in. �oo/c 0 spectlon purposes. (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, judgments,costs and expenses which may In any way accrue against said City In consequence . of the granting of this permit. `-�GNATJORE 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