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R 6126 PERMIT R_ 612 6 APPLICATION FOR CITY OF CUPERTINO NUMBER R- PERMIT INSPECTION DIVISION PERMIT EXPIRATION (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 '7 r 2/ Yoe? f_�/(/R L 1 G t—, RESIDENTIAL COMMERCIAL OTHER OWNER'S - AHAZARDOUS FIRE AREA NAME M M h'L S + � !� YES ❑ If yes s I assembly isrunderstand that a Class A —w NO roof.essembly is requiretl. ❑ Iotrol LC.B.O.N ADDRESS Z� �� 7 �Z Z / �� EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S � \(,� NAME wJ�V_�AS TO BE REMOVED TO BE RETAINED ADDRESS •,+� TYPE OF ROOF COVERING CITY&zip 1 U NG / 0 6 PHONE 7 BUILT-UP ROOF ❑ LICENSE b )„ 'L I . NUMBER r� J� ASPHALT SHINGLES - ❑ LICENSED CONTRACTORS DECLARATION - I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is In lull force entl effect _ ,Lb WOOD SHINGL License Claes Lie.Number Q ❑ Date -k '� Q3 OTHER(SPE s ❑ DBUILDE OWNER-BUILDER DECLARATION PROPOSED hereby affirm Bu that am exempt ham the Contractors License Lew for the following reason. rr (Sec.7031.5,Business and Profedemolish, or rep Code: Any cry or county,which requires e permit e constant,after,Improve,demolish,orrepairany structure,prior to Its Issuance,akar proves the BUILT-UP RO D ftheapplicant for such permit a Ills a signed statement that g islicenseda Section pursuant to the provisions of the ssarctco License Lew(Chapter 8(commencing with Section 7000)of Division 3 le the Business and Professions Code)or that he Is exempt therefrom and the heals for the alleged ASPHALT SHINGLE ❑ exemption.pen.Any violations than five 7031.5 by any s($5 applicant for a permit subjects the applicant to a civil penalty of not more roan flue huntlratl dollars($500).): ❑l,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 Contractor's License Law does not apply to an owner of property who bullae or WOOD SHINGLES Improves thereon,and who does such work himself or through Ms own employees,provided that such Improvements are not Intended or offered for sale,If,ill however,the buildingof pr or Improvement lot ld build or hin prove for purpose sthe owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ not build or improve for purpose of cele.). 40N CA C ❑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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑I am exempt under Sec. ,S&P.C.for this reason Owner Data 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 sell-insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code,for the performance of the work for which this (�� Building 1 '7/O permit Is Issued. \' $elBmlO ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 01 the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's // ,A✓+�� Compensatlo spurs co cardEd Polio number ere: r� Total !� carrier S 'a-��% policy No.�(l L PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WOR ERS' V COMPENSATION INSURANCE N.CQ /, o (This section need not be completed If the permit is for one hundred dollars($100)or leas.) f p 2W ( 9 1 certify that In the performance of the work for which this permit Is Issued.1 shall not employ any person In any manner so as to become subject to the Workers'Compensation Laws of Can- All roofs shall be inspected prior to any roofing material being forme' installed. If a roof is installed without first obtaining an Date Applicant iw Be to remove all new materials for inspection. NOTICE TO subject to the WoP erss'Compelnsal orn provisionls ofethe11cate of Laborr Code,Exemption, mustufo thwldthaecome comply sand will comply with all non point with such provisions or this permit shall be deemed revoked. ti / - I certify that l have read this application and state that the above Information is correct.)agree ,�� to comply with ell city and county ordinances and state laws relating to building construction and ' ITCIas "C"Of etter. hereby authorize representatives of this city to enter upon the above-mentioned property for in.apodia)purposes. -2 `(We)agree to save,pensee w antl keep h ny a y the Clry ai Cupertino egelnet ilebllence u ofthe grantingsts and ol hie perrmilsas which may In any way accrue egelnet said Cly In consequenceLI ANT 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 PERMIT R_ 612 6 APPLICATION FOR CITY OF CUPERTINO NUMBER R- PERMIT INSPECTION DIVISION PERMIT EXPIRATION (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 '7 r 2/ Yoe? f_�/(/R L 1 G t—, RESIDENTIAL COMMERCIAL OTHER OWNER'S - AHAZARDOUS FIRE AREA NAME M M h'L S + � !� YES ❑ If yes s I assembly isrunderstand that a Class A —w NO roof.essembly is requiretl. ❑ Iotrol LC.B.O.N ADDRESS Z� �� 7 �Z Z / �� EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S � \(,� NAME wJ�V_�AS TO BE REMOVED TO BE RETAINED ADDRESS •,+� TYPE OF ROOF COVERING CITY&zip 1 U NG / 0 6 PHONE 7 BUILT-UP ROOF ❑ LICENSE b )„ 'L I . NUMBER r� J� ASPHALT SHINGLES - ❑ LICENSED CONTRACTORS DECLARATION - I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is In lull force entl effect _ ,Lb WOOD SHINGL License Claes Lie.Number Q ❑ Date -k '� Q3 OTHER(SPE s ❑ DBUILDE OWNER-BUILDER DECLARATION PROPOSED hereby affirm Bu that am exempt ham the Contractors License Lew for the following reason. rr (Sec.7031.5,Business and Profedemolish, or rep Code: Any cry or county,which requires e permit e constant,after,Improve,demolish,orrepairany structure,prior to Its Issuance,akar proves the BUILT-UP RO D ftheapplicant for such permit a Ills a signed statement that g islicenseda Section pursuant to the provisions of the ssarctco License Lew(Chapter 8(commencing with Section 7000)of Division 3 le the Business and Professions Code)or that he Is exempt therefrom and the heals for the alleged ASPHALT SHINGLE ❑ exemption.pen.Any violations than five 7031.5 by any s($5 applicant for a permit subjects the applicant to a civil penalty of not more roan flue huntlratl dollars($500).): ❑l,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 Contractor's License Law does not apply to an owner of property who bullae or WOOD SHINGLES Improves thereon,and who does such work himself or through Ms own employees,provided that such Improvements are not Intended or offered for sale,If,ill however,the buildingof pr or Improvement lot ld build or hin prove for purpose sthe owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ not build or improve for purpose of cele.). 40N CA C ❑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 Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑I am exempt under Sec. ,S&P.C.for this reason Owner Data 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 sell-insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code,for the performance of the work for which this (�� Building 1 '7/O permit Is Issued. \' $elBmlO ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 01 the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's // ,A✓+�� Compensatlo spurs co cardEd Polio number ere: r� Total !� carrier S 'a-��% policy No.�(l L PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WOR ERS' V COMPENSATION INSURANCE N.CQ /, o (This section need not be completed If the permit is for one hundred dollars($100)or leas.) f p 2W ( 9 1 certify that In the performance of the work for which this permit Is Issued.1 shall not employ any person In any manner so as to become subject to the Workers'Compensation Laws of Can- All roofs shall be inspected prior to any roofing material being forme' installed. If a roof is installed without first obtaining an Date Applicant iw Be to remove all new materials for inspection. NOTICE TO subject to the WoP erss'Compelnsal orn provisionls ofethe11cate of Laborr Code,Exemption, mustufo thwldthaecome comply sand will comply with all non point with such provisions or this permit shall be deemed revoked. ti / - I certify that l have read this application and state that the above Information is correct.)agree ,�� to comply with ell city and county ordinances and state laws relating to building construction and ' ITCIas "C"Of etter. hereby authorize representatives of this city to enter upon the above-mentioned property for in.apodia)purposes. -2 `(We)agree to save,pensee w antl keep h ny a y the Clry ai Cupertino egelnet ilebllence u ofthe grantingsts and ol hie perrmilsas which may In any way accrue egelnet said Cly In consequenceLI ANT 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