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R 5991hereby affirm that I am licensed untler provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in tuft force and effect. (( License Class e - 3 Lia Numbs .Date G' � Qs' Contractor OWNER -BUILDER DECLARATION hereby affirm that I em exempt from the Contractois License Law for the following reason w . (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, eller, Improve demolish, or repair any structure, prior to Its Issuance, also requires the 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 exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to e civil penalty of not more than five hundred dollars ($500).): ❑ 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 Profes- sions Code: The Contractor's License Law does not apply to an owner of 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 building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did 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 Cade: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractors) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. .B 8 P. C. for this reason Owner Date WORKER'S COMPENSATION DECLARATION hereby affirm under penalty of perjury e one of the /to self tledaration: ❑ I have and calif Section maintain a Certificate of Consent to eeff-insure for Worker's Compensation, as provided for , Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Workens Compensation Inn,sYuuraJncee— carrier�end. Policy'numbe, are: ' / -f Carrier V A19 r �k/L7 Polity No. I7 9 I A T CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.C] (This section need not be completed If the permit Is for one hundred dollars ($100) or less.) I certify that In the performance of the work for which this permit Is Issued, I shell not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Cali. fornia. / Date C �D Applicant N-1 NOTICE O A PLICANT: Il, slier making this Certificate of Exemption, you shoultl become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shalr;be deemed revoked. I certify that I have read this application and state that the above Information Is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentloned property for in. spection purposes. (We) agree to save, Indemnity and it harmless the City of Cupertino against liabilities. Judgments, costs antl expenses which may in any way accrue against said City In consequence Of the OranlinO nl this nermi, PRE -INSPECTION: BATTENS: INSP. WOOD SHAKES WOOD SHINGLES Pc .% D APPLICATION FOR CITY of CUPERTINO NUMBER R- 5991 REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408) 777.3228 PERMIT EXPIRES BUILT-UP ROOF IF WORK IS NOT STARTED 100 DAYS OF PERMIT ISSUANCE OR •WITHIN BUILDING180 ADDRESS DAYS FROM LAST CALLED INSPECTION, /1 ,�� ,r ZOI S-7 S . ©PI6 qS W4.,7 ' OWNERS1 RESIDENTIAL COMMERCIAL OTHER c" , ,,,,(,� cdgc w of HAZARDOUS FIRE AREA YES If NAME— — "" ❑ yes -1 understand that a Class A foof assembly is required NO ❑ Initial I.C.B.O. a ADDRESS- ZO 1 *37 LA -S O/yd" W4_7 EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S . rr'�� /-f t NAME ! �'�' 1 R4h S 1 60 t t..� TO BE REMOVED TO BE RETAINED ADDRESS// -- CITY & ZIP -0 3 ! y C../i-'$ 0,ii W � TYPE OF ROOF COVERING T 1EXISTING PHONE '�SZ� SI YLa LICENSE BUILT-UP ROOF �. NUMBER ASPHALT SHINGLES -0 144 a a4ft,14I hereby affirm that I am licensed untler provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in tuft force and effect. (( License Class e - 3 Lia Numbs .Date G' � Qs' Contractor OWNER -BUILDER DECLARATION hereby affirm that I em exempt from the Contractois License Law for the following reason w . (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, eller, Improve demolish, or repair any structure, prior to Its Issuance, also requires the 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 exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to e civil penalty of not more than five hundred dollars ($500).): ❑ 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 Profes- sions Code: The Contractor's License Law does not apply to an owner of 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 building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did 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 Cade: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractors) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. .B 8 P. C. for this reason Owner Date WORKER'S COMPENSATION DECLARATION hereby affirm under penalty of perjury e one of the /to self tledaration: ❑ I have and calif Section maintain a Certificate of Consent to eeff-insure for Worker's Compensation, as provided for , Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Workens Compensation Inn,sYuuraJncee— carrier�end. Policy'numbe, are: ' / -f Carrier V A19 r �k/L7 Polity No. I7 9 I A T CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.C] (This section need not be completed If 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 shell not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Cali. fornia. / Date C �D Applicant N-1 NOTICE O A PLICANT: Il, slier making this Certificate of Exemption, you shoultl become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shalr;be deemed revoked. 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 hereby authorize representatives of this city to enter upon the above-mentloned property for in. spection purposes. (We) agree to save, Indemnity and it harmless the City of Cupertino against liabilities. Judgments, costs antl expenses which may in any way accrue against said City In consequence Of the OranlinO nl this nermi, PRE -INSPECTION: BATTENS: INSP. WOOD SHAKES WOOD SHINGLES Pc .% D OTHER (SPECIFY) JUL E0 - PROPOSED CITY uFGUI-trnillvV BUILT-UP ROOF ❑ ASPHALT SHINGLES �!✓I' tfp yz, r�INe- WOOD SHAKES WOOD SHINGLES OTHER (SPECIFY) PROVIDE I.C.B.O. REPORT NO. PROVIDE MFGR. INSTALLATION SPECS. AI'I'uOAI ION DATE VALUATION PERMIT FEE Building Seismic Total 6' installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Applicant understands and will comply with all non point source regulations. All roof coverings t be class "C" or better. 20, 6jff�lrl SIGNATURE OF APPLICANT DATE nvor. UAIE I INSP. DATE NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY hereby affirm that I am licensed untler provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in tuft force and effect. (( License Class e - 3 Lia Numbs .Date G' � Qs' Contractor OWNER -BUILDER DECLARATION hereby affirm that I em exempt from the Contractois License Law for the following reason w . (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, eller, Improve demolish, or repair any structure, prior to Its Issuance, also requires the 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 exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to e civil penalty of not more than five hundred dollars ($500).): ❑ 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 Profes- sions Code: The Contractor's License Law does not apply to an owner of 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 building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did 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 Cade: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractors) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. .B 8 P. C. for this reason Owner Date WORKER'S COMPENSATION DECLARATION hereby affirm under penalty of perjury e one of the /to self tledaration: ❑ I have and calif Section maintain a Certificate of Consent to eeff-insure for Worker's Compensation, as provided for , Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Workens Compensation Inn,sYuuraJncee— carrier�end. Policy'numbe, are: ' / -f Carrier V A19 r �k/L7 Polity No. I7 9 I A T CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.C] (This section need not be completed If the permit Is for one hundred dollars ($100) or less.) I certify that In the performance of the work for which this permit Is Issued, I shell not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Cali. fornia. / Date C �D Applicant N-1 NOTICE O A PLICANT: Il, slier making this Certificate of Exemption, you shoultl become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shalr;be deemed revoked. I certify that I have read this application and state that the above Information Is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentloned property for in. spection purposes. (We) agree to save, Indemnity and it harmless the City of Cupertino against liabilities. Judgments, costs antl expenses which may in any way accrue against said City In consequence Of the OranlinO nl this nermi, PRE -INSPECTION: BATTENS: INSP. WOOD SHAKES WOOD SHINGLES Pc .% D APPLICATION FOR CITY of CUPERTINO NUMBER R- 5991 REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408) 777.3228 PERMIT EXPIRES BUILT-UP ROOF IF WORK IS NOT STARTED 100 DAYS OF PERMIT ISSUANCE OR •WITHIN BUILDING180 ADDRESS DAYS FROM LAST CALLED INSPECTION, /1 ,�� ,r ZOI S-7 S . ©PI6 qS W4.,7 ' OWNERS1 RESIDENTIAL COMMERCIAL OTHER c" , ,,,,(,� cdgc w of HAZARDOUS FIRE AREA YES If NAME— — "" ❑ yes -1 understand that a Class A foof assembly is required NO ❑ Initial I.C.B.O. a ADDRESS- ZO 1 *37 LA -S O/yd" W4_7 EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S . rr'�� /-f t NAME ! �'�' 1 R4h S 1 60 t t..� TO BE REMOVED TO BE RETAINED ADDRESS// -- CITY & ZIP -0 3 ! y C../i-'$ 0,ii W � TYPE OF ROOF COVERING T 1EXISTING PHONE '�SZ� SI YLa LICENSE BUILT-UP ROOF �. NUMBER ASPHALT SHINGLES -0 144 a a4ft,14I hereby affirm that I am licensed untler provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is in tuft force and effect. (( License Class e - 3 Lia Numbs .Date G' � Qs' Contractor OWNER -BUILDER DECLARATION hereby affirm that I em exempt from the Contractois License Law for the following reason w . (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, eller, Improve demolish, or repair any structure, prior to Its Issuance, also requires the 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 exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to e civil penalty of not more than five hundred dollars ($500).): ❑ 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 Profes- sions Code: The Contractor's License Law does not apply to an owner of 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 building or improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did 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 Cade: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractors) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec. .B 8 P. C. for this reason Owner Date WORKER'S COMPENSATION DECLARATION hereby affirm under penalty of perjury e one of the /to self tledaration: ❑ I have and calif Section maintain a Certificate of Consent to eeff-insure for Worker's Compensation, as provided for , Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Workens Compensation Inn,sYuuraJncee— carrier�end. Policy'numbe, are: ' / -f Carrier V A19 r �k/L7 Polity No. I7 9 I A T CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.C] (This section need not be completed If 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 shell not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Cali. fornia. / Date C �D Applicant N-1 NOTICE O A PLICANT: Il, slier making this Certificate of Exemption, you shoultl become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shalr;be deemed revoked. 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 hereby authorize representatives of this city to enter upon the above-mentloned property for in. spection purposes. (We) agree to save, Indemnity and it harmless the City of Cupertino against liabilities. Judgments, costs antl expenses which may in any way accrue against said City In consequence Of the OranlinO nl this nermi, PRE -INSPECTION: BATTENS: INSP. WOOD SHAKES WOOD SHINGLES Pc .% D OTHER (SPECIFY) JUL E0 - PROPOSED CITY uFGUI-trnillvV BUILT-UP ROOF ❑ ASPHALT SHINGLES �!✓I' tfp yz, r�INe- WOOD SHAKES WOOD SHINGLES OTHER (SPECIFY) PROVIDE I.C.B.O. REPORT NO. PROVIDE MFGR. INSTALLATION SPECS. AI'I'uOAI ION DATE VALUATION PERMIT FEE Building Seismic Total 6' installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Applicant understands and will comply with all non point source regulations. All roof coverings t be class "C" or better. 20, 6jff�lrl SIGNATURE OF APPLICANT DATE nvor. UAIE I INSP. DATE NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY