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R 51570 0 n FFIrF rnPv PERMIT R_ 515 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 LASTCALLED INSPECTION. BUILDING ADDRESS �/I/� '" -z f 3Cj -4"V�C%v % RESIDENTIAL COMMERCIAL OTHER OWNER'S I HAZARDOUS FIRE AREA YES ❑ If yes -1 understand that a Class A NAME roof assembly is required. ADDRESS 2�� Qfj f vL�j �Q NO Fll Inil I.C.B.O. # EXISTING ROOF COVERING PHONE 252- — Zr,. /A' NUMBER OF EXISTING COVERINGS 1 CONTRA/TOR TO BE REMOVED TO BE RETAINED NAME � ADDRESS ZU,� I TYPE OF ROOF COVERING CITY a zlPZ2-q PHONE --L BUILT-UP ROOF ❑ LICENSE NUMBER — ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provisions of Chapter B (commencing with Section WOOD SHAKES ❑ 7000) of Division 3 of the Business end Professions Code, and my license la In full force end effect c_ WOOD SHINGLES LicenseClass Lic. Numbs - 2 OTHER (SPECIFY) ❑ Date Contractor OWNER -BUILDER DECLARATION I hereby affirm that I em exempt tram the Contractor's License Lew 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 Its Issuance, also requires the rA BUILT-UP R661D ❑ applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions w of the Contractor's License Lew (Chapter g (commencing with Section 700D) of Division 3 of the 996 Business and Professions Code) or that he Is exempt therefrom and the balite for the alleged ASPHALT/SHINGLES ❑ exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to 1'Ui a civil penalty of not more than five hundred dollars ($500).1: the r WOOD SHAKES ulV ❑ ❑I,as owner of property, or my employees with wages ee their sole compensation, will do the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Protes- alons Code: The Contractor's License Law does not apply to an owner of property who builds or Improves WOOD SHINGLES ❑ thereon, and who does such work himself or through his own employees, provided that such Improvements are not Intended or offered for sale. If, however, the bulltling or Improvement Is sold within one year of completion, the owner-bulider will have the burden of proving that he did OTHER (SPECIFY) not build or Improve for purpose of sale.). 01.as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec, 7044, Business and Professions Code: The Contractor's License Lew does not 201� ^1 PROVIDE I.C.B.O. REPORT NO. J apply to an owner of property who build$ or Improves thereon, and who contracts for such projects with a contractor(a) licensed pursuant to the Contractors License Law, C]1 em exempt under Sec. ,B & P. C. for this reason PROVIDE MFGR. INSTALLATION SPECS. Owner Data WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMI I hereby affirm under penalty of perjury one of the following declaration: ❑ I have and will maintain a Certificate of Consent to self -Insure for Workers Compensation, as provided for by Section 3700 of the Labor Cotle, for the performance of the work for which rola p Building / I f � O SBn IV'gl\V htlesued, antl wool Workers Compensation Insurance, as repulsed by Secllon of ( a bar the performance e bon Code, for the pedormence of the work for which this permit Is lasuetl. My Workers orke 'Compeneatlon Insurance carrier endPolicy number ere: ( �L7 K9 Tota ��C� � Carrier Policy No.2+- PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE NAS 1 r, (This section need not be come it the permit Is for one dollars _ L q I of the permit I. of the work for which rola permit la sued, shell not emptoy Is shall($100)not certify that In meaner as In any person so to any manner so as to become subject to the Work pensealon Laws of Cell- All roofR shall be inspected prior to any roofing material being tennis' ',�^ L� installed. If a roof is installed without first obtaining an Date Appllca inspection, I agree to remove all new materials for inspection. subject to the Workeras'Compensation provisions of thefter makrnlghnis /1cate of Laborr Code, Exemption, must forthwshould ltlhbecome comply Applicant understands and will comply with all non point with such provisions or this permit shalf+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 a AT —Rif COV o be class "C" or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. spectlon purposes. (We) agree to Indemnity keep harmless the City of Cupertino liabilities, Z. save, and a alnst judgments, costa and expenses which may In any way accrue against said City n consequence of the granting of this permit. SIGNATURE OF APPLICANT DA 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 n FFIrF rnPv