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R 5659• OFFICE COPY 0 NUMBERR- 5659 APPLICATION FOR CITY OF CUPERTINO INSPECTION DIVISION PERMIT EXPIRATION REROOFPERMIT (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 22\ D OrC�Qr� O RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA J ` 1\+ /1 1/ / C t A , I YES ❑ IF yes —1 understand that a Class A NAME_— YLA WnsW mof assembly is required. NO Initial I.C.B.O. N 2z1�� Orchard EXISTING ROOF COVERING ADDRESS PHONE 9041- qq(o- I kloCv NUMBER OF EXISTING COVERINGS y eS CONTRACTOR'S NAME Res�ns�ble Rn�Fw�a \�C TO BE REMOVED TO BE RETAINED , . ADDRESS Q (� #� CITYBZIP_ 110 N.. f4eD0(-i Min,liw c!03 TYPE OF ROOF COVERING EXISTING (050- gi -to�5I PHONE - BUILT-UP ROOF ❑ LICENSE NUMBER ASPHALT SHINGLES ❑ WOOD SHAKES LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under of Chapter 9 Section provisions (commencing with 7000) of DIVlslon 3 of the Business and Professions Code, and my license is In lull farce and enact. 3a8Aq Class S Lla Number "1�I / WOOD SHINGLES ElLicense �T 2i slblte 'Q.000 Data Ci Contractor fLe5Nn OTHER (SPECIFY) V OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Commodes License Law for the following reason. 7031.5, Business PROPOSED 2 31997 ll// OcT (Sec. and Professions Code: Any city or county which requires a permit to construct, all er, Improve, demolish, or repair any structure, prior to Its issuance, also requires the BUILT-UP ROOF 1:1applicant for Such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's License Law (Chapter g (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 ASPHALT SHINGLE BY: exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to - a clvll penalty of not more than five hundred dollars ($500),): El 1. 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 builds or Improves thereon, and who does such work himself or through his own employees, provided that WOOD SHINGLES ❑ Such Improvements are not Intended or offered for sale. If, however, the building or Improvement is sold within one year of completion, the owner-bullder will have the burden of proving that he did build or Improve for purpose of sale.). OTHER (SPECIFY) El ❑ I, as owner of the property, am 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 contractor(S) licensed pursuant to the Contractors License Law. C]I am exempt untler Sec, ,B 8 R C. for this reason PROVIDE MFGR. INSTALLATION SPECS. Owner out. 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, for by Section l0 22 �, /` �� U�, .00 Building/77 Buildin as provided 3700 of the Labor Code, for the performance of me work for which this permit) Issued. Seismic / 3 0 eve antl will maintain Workers Compensation Insurance, as required by Section 3700 of -the CCCabor Cotle, far the performance of the work for which this permit IS Issued. My Worker's Compensation insurance carrier and Policy number are: / Total ` t�� /r��,L)%� —t rr GG Carrier`,0`c'e1� F ale Policy No.N`- 111 JJ PERMIT AUTHORIZATION DATE CERTIFIcA'rb OF EXEMPTION FROM WORKERS' -..�] / a a - eA �f G '-23 COMPENSATION INSURANCE NC.0 (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 Shall not employ V (( All roofs shall be inspected prior to any roofing material being any parson In any manner so as to become subject to the workers' compensation Laws of can- °`nla. installed. If a roof is installed without first obtaining an Date 201 q1 Applicant inspection, I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply Applicant understands and will comply with all non point pP p y p with such provisions or this permit Shelf; be deemed revoked. SOUfCe 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 above-mentioned property for In. ep (We) purposes. (We) agree to save, and keep harmless me Clry of Cupertino egalnet sequence t/�] ^l/ I �� said Ci judgments, costa and expenses winch may in any way accrue against said City in consequence peIndemnityesw of the granting of this permit. � I / NATURE 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 0