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R 4999• • OFFICE CnPV PERMIT R- 4999 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 RESIDENTI LL COMMERCIAL OTHER OWNERS HAZARDOUSFIRE ARE A � YES If A ❑ NAME I"� roo assembly s required. NO ❑ Initial I.C.B.O. N �'K^'� EXISTING ROOF COVERING ADDRESS PHONE Z 2 — `8 .) NUMBER OF EXISTING COVERINGS CONTRACTOR'S � � NAME K-l%��41 C4—A4 t—F.. Y r`-tT TO BE REMOVED TO BE RETAINED ADDRESSLL 12 pls� Z TYPE OF ROOF COVERING CITY & ZIP -CEJ EXISTING `I /SCC+ �7 Q� �i "7 Cr' t0� PHONE U— / - BUILT-UP ROOF LICENSE NUMBER S - to C-3 ASPHALT SHINGLES ? ©, g LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 em licensed under provisions of Chapter a (commencing with Section WOOD SHAKES 7000) of Division 3 of the Business and Professions Code, and my license Is In full force and 4 21996 affect. C 3 �S1 1 � 3�p ��� WOOD SHINGLES _ License CI a Lie. Number 1 I (;) f Y yr urcn I 114UDate a Conlre"or l OTHER (SPECIFY) PROPOSED OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Bac. 7031.5, Business and Professions Code: Any city or county whit requires a permit no construct, alter, Improve, demolish, or repair any Structure, prior to its Issue also requires the BUILT-UP ROOF applicant for such permit to file a signed statement that he Is licensed urdu .the provisions of the Conireaor'e License Lew (Chapter 0 (commencing with Sect 7000) Ion 3 of the Business and Professions Code) or that he Is exempt therefroril ih a to alleged ASPHALT SHINGLES exemption. Any violation of Section 7031.5 by any applicant far perm le he ebPlicgnn to a civil than five hundred dollars penalty of not more ($500).) "1 WOOD SHAKES ❑1.as owner of the property, or my employees with wag6s a er,pmmpe�lon, will do the work, the IS intended 1 ❑ and structure not or -Us retl sal 0�4; Buslness antl Profen slons Code: The Contractor's License Law tloes not p ply t, o, per of property who builds ar improves thereon. and who does such work himself r u hlSown employees. provided that WOOD SHINGLES such Improvements are not Intended or oHeretl for ow9ver, the building or Improvement'1 1°aoId within one year ofcompletion,theownerbulltlerwilln SIasburdenofprovingthatheditl ,� L�f.,- OTHER (SPECIFY) w L(--1.( not build or Improve for purpose of sale.). C 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(s) llcensetl pursuant to the Contractor's License Law. C I am exempt under Sec. ,B & P. C. for this reason PROVIDE MFGR. INSTALLATION SPECS. Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration C 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this Building / 4 g PY,rm00 I Is Is...of I have and wlll maintain Worker'° Compensation Insurance, a° required by Section 3700 of jJ ( -I j/T /y�� `3/ V V Seismic / e Labor Code, for the performance of the work for which this permit is Issued. My Worker's CeInsurance carrier and Policy number are: Total 074 Carrier J' vi eL11^4Policy No.Z'65—a(LO PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION the ON INSURANCE N.C.0 (This Section need not be come if the permit is for one hot dollarsI ($100) or lesso of the certlty therm tee performance of the work for which this permit is Is Issued, not employ I r00 � shall be inspected prior to any roofing material being Ismsshell any person In any manner so as to became subject to the Workers' compensation Lews of Celi� fornix. installed. If a roof is installed without first obtaining an Dare Applicant inspection, I agree to remove all new materials for inspection. should become subje�rothe Wo ers'C mpena ion provisions of theicate of Labor Code, you must you must forthwith comply Applicant understands and will comply with all non point pP P Y with such provisions or this permit sh&IQbe deemed revoked. source regulations. I certify that Iham read this application information Iscorrect.agree to ordinancenddsttelttheabove ing and and county of ihis ce6 and statelawsthe All roof coven g t be class "C" or better. herebycomplyworize repcity hereby authorize representatives of this city to enter upon tae above mentlOnetl property for in. bove- entl need propertyf ` purposes. sp purr (We) and keep harmless the Clry of st saidCupertinoCi y n pan liabilities, (We) agree to save, expenses coats and expenses which may In any way accrue against said Clry Inconsequence - / �I I �f f0 �� SIGNATURE OF APPLICANT 'DATE of the granting of permit. of the gran 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 CnPV