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99110180 005- q�67 110 IF cl PERMIT 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 ty� RESIDENTIAL " COMMERCIAL OTHER OWNERHAZARDOUS FIRE AREA NAME�iSLC S l� _ YES ❑ It yeas I undassembly req that. Class A 1, roof assembl is required. it NO ❑ Initial LC.B.O.N ADDRESS �� UP[✓ODGe �T EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRAC 'S NAME e F nI TO BE REMOVED TO BE RETAINED 9S //� ADDRESS TYPE OF ROOF COVERING /_7� CITYB ZIP CO &� SJ EXISTING PHONE � ;) / 71-1777 BUILT-UP ROOF LICENSE"- p NASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license is In full force and effect. /• WOOD SHINGLES l�/ License Clessl/� umb 3 1 -�L�� Lic.Ner O2� Detea� 31-,2V Contractor 52 vri S OTHER(SPECIFY) ❑ a0 OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (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 its issuance,also requires the BUILT-UP RO F applicant for such permit to file a signed statement that he is licensed pursuant to the provisions D of the Contractor's License Lew(Chapter 9(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 SH NGLESV 9 1`J`J9 exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to INVUU e civil penalty of not more than live hundred dollars(8500).): WOODSHA �$ ❑I,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 Prates. sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHIN � S E]improves thereon,and who does such work himself or through his own employees,provided that such improvements are not Intended or offered for sale.If,however,the building or improvement Is sold within one year of completion,the owner-builder will 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 builtls or improves thereon,and who contracts for such projects with a contractors)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS. ❑I am exempt under Sec. ,B&P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECIARATION I hereby affirm under penalty of perjury one of the following declaration: ( �/'j I have and will maintain a Certificate of Consent to self-insure far Worker's Compensation, I1—v-/^ / y �� Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Seismic ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of ! c the Labor Code,for the performance of the work for which this permit is issued.My Worker's Z7 v r Total /6q Compensation Insurance carrier and Policy number are: /"-�`�� Carrier�KlsrAY-t r--' lid _ Policy NM�ft 17-0 ` PERMIT AUTHORIZATION DATE CERTIFICAT OF EXEMPTION FROM WO COMPENSATION INSURANCE N.O❑ — f (This section need not be plated if 1h ermil ie for one M1u red tlol rs($100)or lees.) 7 I certify that in the performance of the ork f which this perp is is. d,I shall not employ any person in any manner so as to coca a sable t to the orkers' an nsanon laws f tali- All roofs shall be inspected prior to any roofing material being forma.11-- �� [[��// nstalled. If a roof is ' d without first obtaining an Date) Tl Applica inspection,I agree to r move a new materials for inspection. NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become A 'cant understan s and wi 1 comply with all non point subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply p y with such provisions or this permit shall be deemed revoked. Our regulations. I certify that I have read this application and stela that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and A11r COV gS to e• rb er. hereby authorize representatives of this city to enter upon the above-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 SI NATO OF APPLICANT DATE of the granting of this permit. 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