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R 4996• L] • PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER 8 4996 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 1 Id e RESIDENTIAL COMMERCIAL OTHER OWNER'Sb Z RDO S FIRE AREA I /^� G VES A NAME \� roof assembly s requiredstand NOatClass NO Inal2Wr I.C.B.O. g EXISTING ROOF WYERING ADDRESS 9A/� PHONE "R., 2/S— — 2391? NUMBER OF EXISTING COVERINGS CONTRACTOR'S .�/ 2/�� 1 / / J, NAME V `IIA–ll -yk co vw TO BE REMOVED TO BE RETAINED , i2 H / TYPE OF ROOF COVERING ,�/ri 5,aZZ rn�t [ 9 ©Ct�`y ^ d CITY a ZIP 27 I <-T ' GIS / yv EXISTING pp 99�� �I 0 —(q 7 -7 PHONE 5-34" ❑ BUILT-UP ROOFLICENSE �D NUMBER 7 ASPHALT SHINGLES ❑ LICENSED CON RACTORS DECLARATION I hereby affirm that I em licensed under provisions of Chapter g (commencing with Section WOOD SHAKES ❑ 7000) of Division 3 of the Business and Professions Code, and my license Is In lull force and effect. WOOD SHINGLES License Class J9 Lie. Number OTHER (SPECIFY) ❑ Data CBut offer IOCT OWNER.BUILDERDECLA TION 1 hereby affirm that 1 em exempt from the Contrectore License Law for the following reason. PROPOSED (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct,alter. Improve. demolish, or repair any structure, prior to l nuance, also requires the BUILT-UP ROOF ❑ applicant for such permit to file a signed statement that he is Ilcana $pent to the provision: of the Contractor's License Lew (Chapter B (commencing with Spetlb 1 o1.DlAslon 3 of the Business and Profession: Code) or that he le exempt t ralrarn orf for the alleged ASPHALT SHINGLES ❑ exemption. Any violation of Section 7031,5 byany eppilcan reQp rm e I applicant to e civil penalty of not more then five huntlretl dollars ($500). : �1( � 01,a: owner of the property, or my employees with ae W6le compeneatlon, will do the work, and the structure Is not Intended 9Her b e 0". Business and Profes. sione Code: The Contractor's License Le oe toe nor of property who builds or WOOD SHAKES Improves thereon. and who does Such wo A8 t uyrhryls own employees, provided that WOOD SHINGLES ❑ such Improvements are not Intended or 611 fo .II bwevor, the bulltling or Improvement Is sold within one year of completion, the n-bulloer have the burden of proving that he did OTHER (SPECIFY) ❑ 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 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 contractoge) licensed pursuant to the Contractors License Lew. PROVIDE MFGR. INSTALLATION SPEOS. ❑ I em exempt under Sec. ,B 8 P. C. for this reason ^ERMIT Owner Data WORKER'S COMPENSATION DECLARATION APPLICATION DATE VAL I N FEE I hereby affirm under penalty of perjury one of the following declaration! ❑ I have and wilt maintain a Certificate of Consent to sell -Insure for Workers Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this �s !//../Q/ vI l Y V r l.uf �� j -BUlldlrl g permit IS lveuetl. Y(`v/ `b Seismic Section 3700 of ❑ have and will maintain Worker's Compensation Insurance, permit the Labor Code, for the performance of the work for which this permit Is Issued. My Workers Is I su Compensation Insurance carrier and Policy number are: Total Carrier Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE 100) o (This esctlon need not be completed N the permit is for one hundred dollars ($100) or less.) 1 certify that In the performance of the work for which this is issued, I ' permit shall not emotoy any person In any manner so as to become subject to the Workers' Compenaatlon Laws Cah- II be inspected of Iarni°' root shall pr o any roofing material being installed. If a roof is installed without first obtaining an Dale Applicant inspection, I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If, eller making this Certificate of Exemption, you should become subject Io the Workers' Compeneetlon provisions of the Labor Code, you must forthwith comply Applicant understands and will comply with all non point with such provisions of this permit shell be doomed revoked, source regulations. I certify that I have reed this application end 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 ebova-mentioned property for In. spection purposes: (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may In any way accrue against Said City In consequence at the first at this 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