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R 4698• • OFFICE COPY PERMIT R_ 469 8 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 / , RESIDENTIAL v COMMERCIAL OTHER OWNER'S J �n y HAZARDOUS FIRE AREA YES E] If yes - I understand that a Class A #./0 NAME y roof assembly Is required. NO p Initial I.C.B.O. # 8 G �ka//PCK• EXISTING ROOF COVERING ADDRESS PHONE NUMBER OF EXISTING COVERINGS / TO BE REMOVED �TO BE RETAINED CONTRACTOR'S r ^ NAME AryflLk .1/ �.000/Jr,(✓% ADDRESS / 2 N Qv 3 CITY & ZIP TYPE OF ROOF COVERING EXISTING /' CYox) PHONE BUILT-UP ROOF ❑ LICENSE 7 S NUMBER ASPHALTSHINGLES ❑ LICENSE CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter a (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and WOOD SHAKES ❑ effect. Q License Class ? Ue4 Number 5- Y J ^ °/S WSVu • Date Contractor WOOD SHINGLES OTHER (SPECIFY) OWNER -the DECLARATIONLicense hereby affirm that I am exempts the Conn License Lew for the rem PROPOSED io s e: Any city (Sec. 70315, Business and Professions Code: Any city or county which requires a permit to requires a to prior to Its Issuance, f �9 BUILT-UP ROOF ❑ 7J� apnscntoiler,hImprove,ermit t odea siorrepeatenystructure, permit uantalso eequhesthe flaw a signed statement that he Is licensed pursuant f to the provisions of the of the Co tractor Contractors License Law (Chapter a (commencing with Section 7000) of 3 the the Business and ss and hIsex Code) or that he Is exempt therefrom and the for the le for the ASPHALT SHINGLES ©/ sbasisubjects exemption violation of Anyviolationo of Section by any nt for a permit eublecls the applicant to applicant to civilpe. e t.0 penalty of not more then live hundred t more hundred dollars ($50 ): th wag employees with wages as their sale compensation, will ❑I,as owner eltheproperty,t yee WOOD SHAKES ❑ s. the work, and the structure Is not intended or offered for eels (Sec. 7044, Business entl Profea- i to slons Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or through his own employees, provided that WOOD SHINGLES ❑ 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) E]not build or Improve for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contrectom to construct the project (Sec. 7044, Business and Profesetons 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 contractor(s) licensed pursuant to the Contractor's License Law. ❑ 1 em exempt under Sec. ,B & P. C. for this reason PROVIDE MFGR. INSTALLATION SPECS. Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: ❑ 1 have and w111 maintain a Certificate of Consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. (11®��� Z r� /� LO Building 7k ❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of Jv �J $elSfnlC the Labor Code, for the performance of the work for which this permit Is Issued. My Workers y-�, Ory Compensation Insurance c ter and Policy number are: _ r / (Jf- ��rFL , Total Center—L�� ( VON" 9 PERMIT AUT ORI TION DATE Policy No. CERTIFICATE %r3 OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE NCO (This section need not be completed If the permit is for one hundred dollars ($100) or leas.) I certify that In the performance of the work for which this permit Is issued, I shell not employ All roots'shall be inspected prior to anyllrooling mlitdrial being any person In any manner so as to become subject to the Workers' Compensation Laws of Call. lorria. 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 subject to the Workers' Compensation provisions of the Labor Coda, you must forthwith comply Applicant understands and will comply with all non point pP p y p t with such provisions or this permit shall be deemed revoked. Source regulations. I certify that I have reed this application and elate that the above Information Is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and All roof cD aria sto be class "C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. eppurposes. (We) and keep harmless fns City (We) agree tos save, Cupertino against Ilebllitles, q% peIndemnify esw wa ai judgmenle, costs and expenses which may In any way accrue epelnet said City In conaepuence of the granting of this permit. AffR MAPrCICANT DATE PRE -INSPECTION: PLYWOOD: N- OGRESS: 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