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R 4991a 0 OFFICE COPY EIT NUMBER R- 4991. APPLICATION FOR cNcuPERTINo 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 RESIDENTIAl COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA S?❑ VES If yes - I understand that a Class A NAME L n 1 l C'-_ 1 12A 41t. T e� roof assembly is required. NO Initial I.C.B.O. 1t EXISTING ROOF COVERING ADDRESS 72 !224//=nl /3 A - R ie9g - PHONE .� NUMBER OF EXISTING COVERINGS e3xe- CONTRACTOR'S�i NAME C X� ��O�l Q TO BE REMOVED Gri - TO BE RETAINED ©7t G -Cid ADDRESS,/' T TYPE OF ROOF COVERING CITY &zP �/g( q A8 o5% C_!. Shlllu •l EXISTING PHONE eaV�J_- 4075 ❑ BUILT-UP ROOFLICENSE NUMBER ASPHALT SHINGLES - LICENSED CONTRACTORS DECLARATION hereby affirm that I am licensed under provisions of Chapter 8 (commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code, and my license le In full force antl effect. if WOOD SHINGLES ❑ License Class (1- Lac. Number � („i 7— 3— QG ef,1 egg lFi� C OTHER (SPECIFY) C3Date Contractor . OWNER -BUILDER DE RATION I hereby affirm that am exempt from the Contractor License Lew for the reason. PROPOSED \ (Sec. 7031.5, Business and Any city r county which requires a or requires permit to conscntfor er,Improve, demolish, rep it any or topel suance.pursuant also requires the BUILT-UP ROOF ❑ to file signed staten arruthture, flaw a signed state ani that hal eriead pureuanf to the pro applicant for etch permit to of the Contractors License Lew (Chapter B mencin atibn 7000) of the 3 of the Business and sions I for the Code) or that he le � ro bah the baste for the alleged le ASPHALT SHINGLES ❑ exemption.Any violation of lSection by, p c a ifjlleublects the applicant to ltyofolt more hunch e rival penalty of not more than lave hundred d011 I 0) � ❑I,asownerolthsproperty,ortgyemploya WOOD SHAKES as their a compensation, will do the work, and the structure Is not N eritl d or jj. r Sale (Sec. 7044; Business and Prolas. from, Code. The Contractor's a apply to an owner of property who builds or Improves WOOD SHINGLES ❑ thereon, andwho s eu isinself or through has own employees, provided that such Improvements ere ppof 1 en d Here tl for sale. If. however, the building or Improvement IssoldwithinaneyearofTpm a1 owner-buiderwill have the burden ofproving that hedid OTHER (SPECIFY) ❑ not bulltl or Improve for pu sale.). ❑ I. as owner of the property, em exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors 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 c licensed pursuant to the contractor's license Law. ,,/ �- m exempt ❑ I em exempt under Sec. ,B 6 P. C. for this reason, PROVIDE MFGR. INSTALLATION SPECS. z Date /% WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE 1. I hereby affirm under penalty of perjury one of the following declaration: L' 6v N L!' ❑ I have and will maintain a Certificate of Consent to self -Insure for Worker's Compensation, BUlldln as provided for by Section 3700 of the Labor Code, for the performance of the work for which this g f permit lave and ❑ I have and will Worker's Compensation Insurance, by Section Q JUL 03 199 elsmic yfZ as required 370001 the Labor Coda, for O the pert ark for the performance of the work for which this permit Is Issued. My Workers Compensation Insurance carrier and Policy number are: CI V 1 UI• LI Ir Tota Carrier Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' ^ /y� COMPENSATION INSURANCE (This section need not be completed it the permit Is for one hundred dollars ($100)100) or less.) �_rrllll I certify that In the performance of the work for which this permit is Issued, I shall not emvloy In l( All roofs shall be inspected prior to any roofing material being any person any manner so as to became subject to the Workers' Compensation Laws of Call. forma. installed. If a roof is installed without first obtaining an Data �-�- 4F Applicant -��'4� �_ inspection, I agree to remove all new materials for inspection. othe WorrkereTO CC mpensadan after provisionl5 I the LaboCertificate r Code, Exemption, subjectou mustforthwithlbecome comply Applicant understands and will comply with all non point with such provisions or this permit shalgba 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 authorize representatives of this city to enter upon the ebove-mentioned property for In. spection purposes. (We) agree to save, Intlemnity end keep harmless the City of Cupertino against Ilabllltlae, /jy.�//f1 , 7-3-� Q� at the granting Of thispermit ee which may In any way accrue against avid Clfy an consequence SIGNATURE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY