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R 6135 APPLICATION FOR CITY OF CUPERTINO PERMIT R- 6135 . INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 100 DAYS OF PERMIT ISSUANCE OR • 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS IV '1 1T�I�y^( � �?>co I � •r ' ` ` ' —' RESIDENTIAL COMMERCIAL OTHER OWN Ws HAZARDOUS FIRE AREA dAW �I A YES ❑ If yes-I understand that a Class NAME_ W V- NO root assembly is required tlal� I.C.B.O.#_> ADDRESS ' Ynl[_Ar4ie�iicn�PEXISTING ROOF COVERING _ 5 O t NUMBER OF EXISTING COVERINGS PHONE CONTRACTOR'S I. �/1 �•r�f I/•I /� NAME ci[O� l V'v� CAJ p TO BE REMOVED TO BE RETAINED ADDRESS 2 �. I n t/,r�.{•h�.(�!n n._ - / •/� _„ ,� / OO' CITU 8 ZIP `1 \/1 lU'`L-I t �f(y�,Q„ 1 GfVUTA .IIJ 1 TYPE OF ROOF COVERINGEXISTINGO PHONE BUILT-UP ROOF - � ❑ LICENSE j//�,� n NUMBER "�UIY ASPHALT SHINGLES/� x [. LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter a(commencing'with Section WOOD SHAKES //h 7000)of Division 3 of the Business and Professions Cotle,and my license Is In full farce and (/.�" effect. lWOOD SHINGLES Licanse CI -1 C Lic.Number (D qa Date Contractor C4 M (A60 OTHER(SPECIFY) D OWNER-BUILDER DECLARATION PROPOSED OCT 1 .1998 I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec.7031.5,Business and Professions Coda: Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF El app for such permit to file a signed statement that he is licensed pursuant to the provisions It the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the ' Business and Profession.Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES By exemption.Any violation of Sefton 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not mare than live hundred dollars(55001.): ED 1.es 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- °lana Cotle:The Contractor's 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 Elsuch Improvements are not intended or offered for sale.If,however,the building or Improvement A Is sold within one year of completion,the owner-budder will have the burden of proving that he did OTHER(SPECIFY) (� not bu lid 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(.)licensed pursuant to he Contractors License Law. PROVIDE III INSTALLATION SPECS. E]I am exempt under Sec. ,B 6 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: ❑ ideaand willmfnt37a of Certificate the bof Consent to self-Insure forWorker's Compeneatlon, � ®// ^t7/ I� f �� Building i as provided for byill Section 370001 the Labor Consent the performance for work Car ompensation hthis // (Al `XJ p mit' Issued. Seismic hv0 and will maintain Worker's Compensation Insurance,as required by Section 3700 of ,the or Code,for the performance of the work for which this permit is Issued,My Worker's Total Compensation no. nee c rrier end Palls numA�be`�r�@1�e: q,� Carrier �t-P.OucyNo. rl 1� ' I PE UTHORIZATIO DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE 100)a /O /—L Q (This section need not be completed If the permit Is for one hundred dollars($100) r leas.) �J �. 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 r0 all be inspected prior to any roofing material being .f°`me. installed. It a roof Is installed without first obtaining an Date Applicant - inspection,I agree to remove all new materials for inspection. subjeT CE ct t.the TO APPLICANT. mpensetl n provisions of theflLabor CodefCate of °yolu must forthwld become ith comply Applicant understands and will comply with all non point with such provisions or this permit shelgbe 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 cov rings to be cl ss"O"Ol�befler. hereby authorize representatives of this city to enter upon the above-mentioned property for In. spection purposes. (We)agree to save,Indemnify and keep harmless the City of Cupertino al Ilabililies, judgments,coats and expenses which may In any way accrue against said City In consequence - of the gramIng of this permit. SI GRATURE OF A?PLICJ1,NT V DATE PRE-INSPECTION: PLYWOOD: IN• ESS: 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