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R 6070/(2100 Mari AVS • 0 OFFICE COPY PERMIT R_ 6 7 APPLICATION FOR CITY OF CUPERTINO NUMBER 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 �V I�JQ(J RESIDENTIAL COMMERCIAL OTHER - OWNER'S HAZARDOUS FIRE AREA C.C1/l% YES ❑ I Class NAME' / ' Vl.l-f.1 assembl ist required. NO NO ❑ Initial I.C.B.O. N _ f EXISTING ROOF COVERING 3 F �t ADDREss /O�/� PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S 7!^J� 1/� DI �l / ©UN �PU Il SOI NAME l TO BE REMOVED TO BE RETAINED ADDRESS _J bC&G TYPE OF ROOF ERIN CITY&ZIP V 7YJ 1,t t4 EXISTING u3 PHONE / / BUILT-UP ROOF LICENSE / ^7 2 Z 3 NUMBER U ! ASPHALT SHINGLES ❑ WOOD SHAKES LICENSED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provisions of Chapter g (commencing with Section 7000) of Division 3 of Iha Buelness entl Professions Code, and my license Is In full force and ,/1 affect. �,_ 39 .� �' ,� / License Clew Lic. Number WOOD SHINGLES '❑ �./� fs-ZS'-f n, r 2 OTHER (SPECIFY) ❑ Data Contractor . OWNER BUILDER DECLARATION hereby affirm that em exempt from the Contractor's License Law for the following reason, PROPOSED in (Sec. 7031.5, Business and Professions Any city or county which requires a permit to anyucture, it any to Issuance, also requires the constrapplicant Improve, demoto BUILT UP ROOF ❑ or such he is licenseor for such permit to file a signed statement that file signed statement pursuant to the provisions islicensedSection of the of the Conlractore License Lew (Chapter B (commencing with Sactlon 7000) of Division 3 0l the g Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged ASP $HI exemption, Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to e civil penaltyof not more than Ilva hundred d0 liars ($500).1: ❑1, 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. WOOD SHAKE ❑ sions Code: The Contractor's License Lew does not apply to an owner of property who builds or improves thereon, does W0A .g. AW9 ❑ D and who such work himself or through his own employees, provided that such Improvements are not Intended or offered for sale. ll, however, the building of Improvement Is sold within one year of completi(In, the owneabullder will have the burden of proving that he did not build or Improve for purpose of sale.). By OTHER (SPECIFY) ❑ [:11, as owner of the property, am exclusively centraodng with licensed contractors to construct the project (Sec. 7044, Business and Professions Coda: The Contractor's License Law does not PR RT 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. ❑ 1 em exempt under Sec. ,B 8 P. C. for this reason PROVIDE MFGR. INSTALLATION SPECS. Owner Date WORKER'S COMPENSATION DECORATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penally of perjury one of the following declaration: ❑ 1 have and wilt maintain a Certificate of Consent to self -Insure for Worker's Compensation, / Q as provided for by Section 3700 of the Labor Code, for the performance of the work for which this - ^ G 4 _ 0� BUI Iding permit Is Issued. I have /S3�S. �/�/� /��] Seismic ❑ and will maintain Workers Compensation Insurance, as required by Section 3700 0l the Labor Coda, for the performance of the work for which this permit Is Issued. My Workers 20 ?e / O Compensation Insurance terrier and Policy number are: Total C �D -� l Carrier 1—l! / ZwC P°11cyNAAK-20ZCf&S-S PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' _ COMPENSATION INSURANCE N.C{] (This section need not be completed II the permit IB for one hundred dol len (5100) or less.) .� I certify that In the performance of the work for which this permit Is Issued, I shell not employ All roofs shall be inspected prior to any roofing material being any person In any manner so as to become subject to the Workers' Compensation Laws of Cali. °`nie. ��?15 �I,,A �//� installed. If a roof is installed without first obtaining an � Date ApplicaE nt ,r'!� inspection, I agree to remove all new materials for inspection. NOTecome TO APPLICANT: It, aft subject 2 the Workers' Compensation previsionls of the riLabor Code, cate of you mustuforthwllthaComply Applicant understands and will comply with all non point with such provisions or this permit shall be 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 or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. ap purposes. (We) and may harmless the City of Cupertino (We) agree save, liabilities, J U yagainst In con s penes w I ofthe gran costs and expenses which may In any way accrue against said Clry In consequence ohne granting of permit. 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 ACCESS TO -ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY