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R 493211 a 11 OFFICE COPV PERMIT R_ 4 9 3 2 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 - //,7J �-+ RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA �V YES ❑ If yes — I understand that a Class A NAME �h roof assembly is required. NO ❑ Initial I.C.B.O. N / / / 1 22 r �� �/� EXISTING ROOF COVERING ADDRESS �✓/1 ���d wit ,' • S v�t'rC,�7 PHONE y6o� SSS S��S' NUMBER OF EXISTING COVERINGS TO BE REMOVED TO BE RETAINED CONTRAC ORA'S'�JJ/ NAME /y�ItJ "+�x! "/O T//r g ADDRESS y a CITY&ZIP y67✓9r�i T03Q. C/Y J�7w ✓O.i P, r/iy /•ir/,Z^� TYPE OF ROOF COVERING . XI " �k�0-� PHONE / "Z� BUILT-UP ROOF ❑ LICENSE NUMBER ;SO /�,$- ASPHALT SHINGLES ❑ , WOOD SHAKES LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is In full force and effect. ,6��.P SQ7S yJ� � WOOD SHINGLES ❑ License Class x. Lie. Number � `tip OTHER (SPECIFY) ❑ Data Contractor OWNER -BUILDER DECLARATI PROPOSED hereby affirm that em exempt from the Contractor's License L for the following reason. (Sec. 7031.5, Business and Professions Code: Any city or county' - requires a permit to construct, alter, Improve, demolish, or repair any structure, prior tb its e, also requires the BUILT-UP ROOF❑ applicant for such permit to file a signed statement that het•license rt�u i to the provisions . of the Contractor's License Law (Chapter 9 (commencing wI S 00) of Division 3 of the Business Professions Code) p�Q and or that he Is exemal there the basis for the alleged Any Section 7031.5 dpplicant ASPHALT SHINGLES � Y66 o V exemption, violation of by anyy fo rmit subjects the applicant to a civil penalty of not more than five hundred Ibrs ($500 WOOD SHAKES 1] 1, as owner of the property, or my empl see wit see thelrsole compensetlon, will do work, �Theestructure Is not La dvFp usiness and Profes- lops sis Cotlee Contrector's LceIntended improves thereon, Thense of pply toeen3ownerof pBoperty who builds or antlwhors U such work se rthroughnowne employees, provided that le8m WOOD SHINGLES + such Improvements are not intended or offers Jet site. If, however, the building or Improvement ��.© 1. Is sold within one year of completion, the owner -builder will have the burden of proving that he did OTHER (SPECIFY) G\�� ❑ not build or Improve for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contracts® 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 contractors) licensed pursuant to the Contractor's License Lew. ❑ I em exempt under Sec. ,B 8 P. C. for this reason PROVIDE MFGR. INSTALLATION SPECS. OwnerDate WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: ❑ 1 have and will maintain a Certificate Consent to for Worker's / /0��� of self -insure Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this t0[/ / /1/DO, a 6 7� Building l_ 60 germy la issuetl. C�'i have antl will maintain Worker's Compensation Insurance, ee required by Section 3700 of th Labor Code, for the the for is B91SfnIC performance of work which this permit issued. My Worker's Compensation syren�c/e carrier e��n—d'-••Policy nymber are: TOSBI ! 3% 9n .V it, �ZihC PERMITA ORIZATION DATE Carrier PollcyNo. `?y� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.O (This section need not be completed if the permit is for one hundred dollars ($100) or lase.) 1 that in certify the performance of the work for which this permit is issued, Ishell not employ All r ofs shall be inspected prior to any roofing material being any person In any manner so as to become subject to the Workers' Compensation Laws of can- forma. 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: It, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply Applicant understands and will comply with all non pP P Y point with such provisions or this permit shell be doomed revoked. Source regulations. , I certify that I have read this application and state that the above information la 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 above-mentloned property for In- spection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, /f �T✓,,/ �Qfjl✓\ /� S/ 44 lodgments, costs end expenses which may In any way accrue against said City In consequence of the graining et itis permit. _ SIGNATU 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPV