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R 6164 PERMIT R_ 6164 . APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT 1408)ern-1118 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 160 DAYS OF PERMIT ISSUANCE OR • 160 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS '{I' 903 • ,7, � " /!n RESIDENTIAL COMMERCIAL OTHER OWNER'S - i HAZARDOUS FIRE AREA NAME � � YES ❑ Ifyes–Iunderstand that. Class roof assembly is required. NO ❑ Initial I.C.B.O.q ADDRESS—5 a VIS 41 EXISTING ROOF COVERING PHONE � NUMBER OF EXISTING COVERINGS , • CONTRALTO S .NAME SAgQ { , TO BE REMOVED TO BE RETAINED 171 CITY&ZIP D TYPE OF ROOF COVERING CITU 8 ZIP PHONE �(Jj BUILT-UP ROOF ❑ LICENSE ❑ NUMBER ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION hereby iaffirmnion that em licensed under provisions of Chapter 8(commencing with Section and WOOD SHAKES 700 0)of Division 3 of the Business and Professions Code,and my license Is In lull force entl effect' WOOD SHINGLES License Claes�.�9 Us.Number Date contractor &Q41l &VIllOTHER (SPECIFY) D OWNER-BUILDERDECLARATIONPRoposED .DEC 2 81998 hereby ,Bu that am exempt from the e: Any city License Lew for the a reason. (Sec.7031.5, ,Improve and Professions Code: Any dry or county which requiresalso a requires to applicucLalter,Improve,to ish,or repair a signed statement prior taIts Issuance,alsomthe BUILT-UP ROOF ❑ eppllc Contractor's etch permit to flaw a egad statement that he Is licensed pu 00)of the proof the of the Contractor'ssloe License Lew(Chapter 6 is ex a exempt with Section 7000)of for the 3 of the • exemption. and violation of Code)or that he le exempt antforam and the baste for the alleged ASPHALT SHINGLES By n exemption.Any violation of Section hundred by any applicant for a permit subjects the applicant to e civil penalty of not more than five hundred employees dollars with wag.): WOOD SHAKES❑1,k, owner of the properly,or to employees with wages as(her sale compensation,will do ❑ the work,and the structure Is not Intended or offered for see(Sec.7044,Business entl Pros or Islons mproCode:The,anwho d License Law does not apply toenowner of property who builds or WOOD SHINGLES Improves o thereon,n,end who does such workhimselffor or through his awn employees,provided that such Improvements year are not completion, leb n,the offered for see,ill however,the buiburdingden pr or ImprovementIs not ld bull thinor prove for purpose sthe ownerbulltler will have the burden of proving that he dltl OTHER(SPECIFY) not build or Improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct ATh the project(Sec.7044,Business and Professions Coda:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. W42C J apply to an owner of property who builtls or Improves thereon,and who contracts for such projects with a contractorte)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. C]I am exempt under Sec. ,B&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: i/ ❑I have and will maintain a Certificate of Consent to selbinsum for WDrker'e Compensation, I -A- 01 i Z [� / ( 0 as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this yi Q Building Q permit Is Issued. $eISfT11C ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of p/oO �O the Labor Code,for the pedormance al a work for which this permit Is Issued.My Workers ` I TORI Compenear n Insurance ceirler and ofn�b�are�:e_ Carrier N !�[ez��oclEyNoPERMITAUTHORIZATON DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.0] `p�/Y (This section road not be completed If the permit Is for one hundred dollars($100)or lees.) 2—ZJ I certify that In the performance of the work for which this permit Is Issued, shell not employ any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All rogf shall be inspected prior to any roofing material being form&. instAled. 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,alter making this Certificate of Exemption,you should become Applicant understands and will Com subject to the Workers'Compensation provielone of the Labor Code,you must forthwith comply pP ply with all non point 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 constructor.and All roof co Ings to be class"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. spection purposes. e (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, C �iiA of the gran conte and permit. which they In any way accrue against said Clry Inconsequence SIGNATURE OF APPL CANT r 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 OFFICE COPY . . PERMIT R_ 6164 . APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT 1408)ern-1118 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 160 DAYS OF PERMIT ISSUANCE OR • 160 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS '{I' 903 • ,7, � " /!n RESIDENTIAL COMMERCIAL OTHER OWNER'S - i HAZARDOUS FIRE AREA NAME � � YES ❑ Ifyes–Iunderstand that. Class roof assembly is required. NO ❑ Initial I.C.B.O.q ADDRESS—5 a VIS 41 EXISTING ROOF COVERING PHONE � NUMBER OF EXISTING COVERINGS , • CONTRALTO S .NAME SAgQ { , TO BE REMOVED TO BE RETAINED 171 CITY&ZIP D TYPE OF ROOF COVERING CITU 8 ZIP PHONE �(Jj BUILT-UP ROOF ❑ LICENSE ❑ NUMBER ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION hereby iaffirmnion that em licensed under provisions of Chapter 8(commencing with Section and WOOD SHAKES 700 0)of Division 3 of the Business and Professions Code,and my license Is In lull force entl effect' WOOD SHINGLES License Claes�.�9 Us.Number Date contractor &Q41l &VIllOTHER (SPECIFY) D OWNER-BUILDERDECLARATIONPRoposED .DEC 2 81998 hereby ,Bu that am exempt from the e: Any city License Lew for the a reason. (Sec.7031.5, ,Improve and Professions Code: Any dry or county which requiresalso a requires to applicucLalter,Improve,to ish,or repair a signed statement prior taIts Issuance,alsomthe BUILT-UP ROOF ❑ eppllc Contractor's etch permit to flaw a egad statement that he Is licensed pu 00)of the proof the of the Contractor'ssloe License Lew(Chapter 6 is ex a exempt with Section 7000)of for the 3 of the • exemption. and violation of Code)or that he le exempt antforam and the baste for the alleged ASPHALT SHINGLES By n exemption.Any violation of Section hundred by any applicant for a permit subjects the applicant to e civil penalty of not more than five hundred employees dollars with wag.): WOOD SHAKES❑1,k, owner of the properly,or to employees with wages as(her sale compensation,will do ❑ the work,and the structure Is not Intended or offered for see(Sec.7044,Business entl Pros or Islons mproCode:The,anwho d License Law does not apply toenowner of property who builds or WOOD SHINGLES Improves o thereon,n,end who does such workhimselffor or through his awn employees,provided that such Improvements year are not completion, leb n,the offered for see,ill however,the buiburdingden pr or ImprovementIs not ld bull thinor prove for purpose sthe ownerbulltler will have the burden of proving that he dltl OTHER(SPECIFY) not build or Improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct ATh the project(Sec.7044,Business and Professions Coda:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. W42C J apply to an owner of property who builtls or Improves thereon,and who contracts for such projects with a contractorte)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. C]I am exempt under Sec. ,B&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: i/ ❑I have and will maintain a Certificate of Consent to selbinsum for WDrker'e Compensation, I -A- 01 i Z [� / ( 0 as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this yi Q Building Q permit Is Issued. $eISfT11C ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of p/oO �O the Labor Code,for the pedormance al a work for which this permit Is Issued.My Workers ` I TORI Compenear n Insurance ceirler and ofn�b�are�:e_ Carrier N !�[ez��oclEyNoPERMITAUTHORIZATON DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.0] `p�/Y (This section road not be completed If the permit Is for one hundred dollars($100)or lees.) 2—ZJ I certify that In the performance of the work for which this permit Is Issued, shell not employ any person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All rogf shall be inspected prior to any roofing material being form&. instAled. 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,alter making this Certificate of Exemption,you should become Applicant understands and will Com subject to the Workers'Compensation provielone of the Labor Code,you must forthwith comply pP ply with all non point 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 constructor.and All roof co Ings to be class"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. spection purposes. e (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, C �iiA of the gran conte and permit. which they In any way accrue against said Clry Inconsequence SIGNATURE OF APPL CANT r 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 OFFICE COPY . .