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R 4893 APPLICATION FOR clTv of cuPERTINo NUMBIERR- 4893 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 1110 DAYS OF PERMIT ISSUANCE OR . 1110 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS RESIDENTIAL COMMERCIAL OTHER OWNER'S �mHAZARDOUSFI REA NAME W F�iIYES ❑ understand that ClassA roof bN is requiredired. NO Initial LC.B.O,p ADDRESS � { �w2G' �/` - EXISTING ROOF COVERING 1 s PHONE v D V NUMBER OF EXISTING COVERINGS I S All CONTRACTOR'S /ryy NAME TO BE REMOVED TO BE RETAINED ADDRESSn c^ ,M� ��1 TYPE OF ROOF COVERING CITY&ZIP 16 L2 I l �-bC-/lam. EXISTING • PHONE ��r n (p q- �( qa BUILT-UP ROOF ❑ LICENSE NUMBER C091&Oa- ASPHALTSHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter g(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 9 License Claes Lic.Number MEI Date Z contractor r. OTHERRBCI 1p ❑ OWNER-BUILDER DECLARATION (://1 /O96 //L (Sao 7031.f 5'Business and Proffirm that I am essions ifollowingt from the Contractor's License Law for the ssions Code: Any city orr county wwhichreg hes ermit to PROPOSEDL/1- UVr-Crl I fl construct,alter,Improve,demolish,or repair any structure,,p r to Its issuance,also requires the BUILT-UP ROOF lU ❑ applicant for such permit to file a signed statement that he l d pursuant to the provisions of the Contractors License Law(Chapter a(commencing with iak7000)of Division 3 of the Business and Professions Corte)or that he is exempt 11tteFefrom a basis for the alleged ASPHALT SHINGLES • exemption.Any violation of Section 7031.5 by any tppItant l r a r subjects the applicant to a civil penalty of not more than floe hundred do11 ( .) WOOD SHAKES ❑I,as owner of the property,or employe with we q .7 sole compensation,will do ❑ the work,and the structure is not Intended or Brad f a{fisc.7044,Business and Profes- sions Code:The Contractor's Lfcenso Le a no a y tp n owner property who builds or WOOD SHINGLES Improves thereon,end who does such w m rGGtfgh his own employees,provided that ❑ such Improvements are not Intended or o e Ie, ,however,the building or Improvement Is sold within one year of completion,the wwderi III have the burden of proving that he did OTHER(SPECIFY) El build or Improve for purpose of sale.). `� ❑I,as owner of the property,am exclusly contracting with licensed contractors to construct the project(See.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE LC.B.O.REPORT NO. apply to an owner of property who builds or Improves thereon,and who contacts for such projects with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B S P.C.for this reason �' Owner Dat 'APPLICATIONLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: ❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this mit , 1�� p Issued. r /t7/ Seismic � have end wQ w, ill maintain Workers Compensation Insurance,as required by Section 3700 01 I bar Code,for the performance of the work for which this permit is Issued.My Workers Total ompeneetlo9\Q'aYYre��n� carrlar aol/icy number are: p 1r,. Carrier U> � r X/'-- Policy No.'�yl�V�rPERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' _ r COMPENSATION INSURANCE NC' �w (Thio section need not be completed If the permit is for one huntlred dollars($100)or less.) G I certify that In the pelf rmence of the work for which this permit is Issued,I shall not employ any person In any manna so as to become subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to AlViToofing material being tornla. installed. If a roof is installed without first obtaining an DateTO Applicant inspection,I agree to remove all new materials for inspection. d become subject thee Wor ers'Compen aton provisions ofthlelLabor Code,cate of Exemption, mustuforthwitth comply Applicant understands and will comply with all non point with such provisions or this permit shat@be deemed revoked. source regulations. I certify that I have road this application and state that the above information is correct.I agree to comply with all airy and county ordinances and state laws relating to building construction,and All roofof gstObe class"C", better, 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 expensea which may in any way accrue against said City In consequence • of the granting of this permit. SIGNATURE OF APPLICA DATE PRE-INSPECTION: PLYWOOD: IN-PROGRES . 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 COPY