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00020100C] 0 -32-1 1V/ OZ/ O OOZ©7 f0'O OFFICEICOPY PERMIT 4W 1R - 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 1 RESIDENTIAL COMMERCIAL OTHER OWNERTS HAZARDOUS FIRE AREA / _ nH l YES El 11yes - I understand that a Class A : NAME L `�V G�h n !l(� If assembly is required. NO ❑ Initial I.C.B.O. q �j � /,� �� nr� EXISTING ROOF COVERING ADDIF �!✓�• 1 Oy NUMBER OF EXISTING COVERINGS PHONE CONTRACTOR'S r r /yam NAME TO BE REMOVED TO BE RETAINED ADDRESS TYPE OF ROOF COVERING clTv a zIP EXISTING PHONE �yl� -5�•QC.7 BUILT-UP ROOF 2�❑ � ,��� LICENSE NUMBER / ASPHALT SHINGLES � LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section WOOD SHAKES �J 7000) of Division 3 of the Business and Professions ode, and my license is in full force and .neat' WOOD SHINGLES License Class Lic. Number OTHER \ 11 Data Contractor OWNER -BUILDER DECLARATION (SPECIFY) rQ_ /f- 'N U 'r�1 License Law for the following reason. I hereby affirm that I am exempt from the e: Any Business and Professions Code: Any city or county which requires e permit to PROPOSED U FEB 4 �000 con huct, alt or repair any applicant, altos improve, structure, prior In Its issuance, also requires the BUILT-UP ROOF -31 flaw a signed cNal purl f 1D the provisions applicant for such permit to file signed statement it lice r 9 of the ss and lProf License Lew (Chapter 9Isexpt with Section 7000) of Division 3 of the a (commencing ctio Basins and Professions Code) or that he Is exempt and the basis for the alleged ASPHALT SHINGLES antforam exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to By a civil penalty of not more than five hundred dollars ($500).): WOOD SHAKES El 1, as owner of the property, or employees withh wages as their sole compensation, will do ❑� the work, and the structure Is not intended or offered for solo (Sec. 7044, Business and Profes- sions Code: The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES E3improves thereon, and who does such work himself or through his own employees, provided that such improvements are not Intended or offered for sal.. If, however, the building or improvement is said 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 Coda: 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 contmcmr(s) licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS. I] 1 am exempt under Sec. .B 8 P. C. for this reason Owner Date - APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: have antl will maintain a Certificate of Consent to sell -insure for Worker's Compensation, as rovitled for by Section 3700 of the Labor Code, for the performance of the work for which this O Building permit is issued. Seismic 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of / the Labor Code, for the performance of the work for which this permit is issued. My Worker's Total Compensation Insurance carrierx and y number are: Cantor ��' `/maPolicy No. Iiii � ? PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or cress.) _ I certify that in the performance of the work for which this permit Is Issued, I shall not employ - any person in any manner so as to became subject to the Workers' Compensation Laws of car- All roofs shall be inspected prior to any roofing material being forms. installed. If a roof is installed without first obtaining an Date Applicant inspection, I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become Applicant understands and will comply with all non point pP P Y P subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply 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 construct®n, All roof coverings to be class' or flare hereby authorize representatives of this city to enter upon the above-mentioned property for in. spection purposes. ea five) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, casts and expenses which may in any way accrue against said City in consequenceSILT` ATUR LI 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICEICOPY