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R 4923 PERMIT R_ 4923 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-,3228 PERMIT EXPIRES IF WORK IS NOT STARTED ' WITHIN DAYS PERMIT ISSUANCE OR WI DANSS FROM LAST CALLED INSPECTION. BUILDING ADDRESS �� RESIDENTIAL' COMMERCIAL OTHER owNER HAZARDOUS FIRE AREA NAM YES ❑ froof assembly s rrequirrede Class A .NO ❑ Initial I.C.B.O.R ADDRESS EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS -� - CONTRACTORS NAME -1,� (� , NAME l/ ' _\�ynnL\ TO BE REMOVED LA TO BE RETAINED ADDRESS 4E OF ROOF COVERING CITY a ZIP efirl3 EXISTING BUILT-UP ROOF ❑ LICENSE NUMBERAli ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby aHlrm that I am licensed under provisions of Chapter 5(commencing with Section WOOD SHAKES 7000)of Division 3 ol.the Business and Professions Cade,and my license is In full force and effect. 2-.2— < WOOD SHINGLES E]License Class� Lia Number - Date �✓ OTHER(SPECIFY) El OWNER-BUILDER Contractor OWNER-BUILDER DECLARATION PROPOSED hereby affirm that am exempt from the e: Any city License Lew for the following rens ZKIZ (Sec.7031.5,Business end demolish, Profeor rep Code: Any city or county which requires a permit to conlicanstruct.alter,Improve,to file signed staair anystructure,h is licenseor to issuance,see requires the BUILT-UP ROOF �( applicant for such permit to Ills a signed r 9(commencing that g le licensed pursuant to the provolone • of the Contractor's License Lew(Chapter h(commencing with om and 7000)basis for 3 of the Busexempio and violation Of Code)or that he Is exempt Therefrom and the basis for the ica t to ASPHALT SHINGLES exemption.Anyty violationo t more of than tion 7031.5 by any sapplicant($5 ).for a permit subjects the applicant to ,�,�/• e clue,as owe net more than Ove hundred doers with wage WOOD SHAKES L� ❑I,se owns of the property,or to dedemployees with wages as their Bole compensation,will s. the work,and the Contractor's Is not Intended or offered for ase(Sew owner at Business and builds o- atonvesth The Contractor'oessuch workhi snet apply ghhis own employees,pho rovide that WOOD SHINGLES improves!hereon,and who does deco work himself or through his own employees,provided!hal ❑ such improvements are not completion, leb n,or offered for Bale. ill however,the en of pr or Improvement is sold not or hin Imprne ove sr purpose sal downer-bulltlerwlll have the bureau of proving that hedid OTHER(SPECIFY) ❑ not build or Improve for purpose of eale.)- ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contrasor's License Law does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of property who builds or Improves thereon,and who contracts for such projects with a c m licensed pursuant to the Contractor's Licensee Lew. PROVIDE MFGR.INSTALLATION SPECS. ❑ emm exempt under Sec. ,B$P.C.for this reason L 0 A P , WORKER'S COMPENSATION DECLARATION owner Date AP !CATION DATE VALUATION PERMIT FEE I hereby aHlrm under penalty of perjury one of the following declaration: ❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, 3 �A Bullding ` 4� as provided for by Section 3700 of the Labor Code,for the performance of the work for which this try JJS permit is issued. Ut GVy-. SBISfnIC ❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of f_ry711tr the Labor Code,for the performance of the work for which this permit is issued.My Worker's V 'Compens n Insure ss.Farrier end Policy number are: .yam �.���. (—\� Total Carrier PolicyNwWZ7�=` PERMIT AUTHORIZATION DATE CERTIFICA E OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE . �k ^ (Tole section need not be completed it the permit is for one hundred dollars($100100 o)or less.) I certify that In the performance of the work for which this permit Is Issued,I shell not employ any person In any manner so as;to become subject to the Workers'Compensation Laws of Cell. All roofs shall be inspected prior to any roofing material being fornia. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. NOTICsubject to the WorkeTO rs'APPLICANT:Compensation n provisions ofthis thelcate of Laborr Code.you mustuforthwld become ith comply Applicant understands and will comply with all non point with such provisions or this permit shalObe deemed revoked. Source regulations. I certify that I have reed 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 All roof coverings to be class"C"or 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 hatellitles, r • j f the grpe costa and expenses which may In any way accrue against eoltl City In consequence or and l7rammg ohms permu. SIGNATURE OF APPLICANT 'DATE PRE-INSPECTION: PLYWOOD: IN-PROGRESS: INSP. DATE NSRDATE 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_ 4923 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-,3228 PERMIT EXPIRES IF WORK IS NOT STARTED ' WITHIN DAYS PERMIT ISSUANCE OR WI DANSS FROM LAST CALLED INSPECTION. BUILDING ADDRESS �� RESIDENTIAL' COMMERCIAL OTHER owNER HAZARDOUS FIRE AREA NAM YES ❑ froof assembly s rrequirrede Class A .NO ❑ Initial I.C.B.O.R ADDRESS EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS -� - CONTRACTORS NAME -1,� (� , NAME l/ ' _\�ynnL\ TO BE REMOVED LA TO BE RETAINED ADDRESS 4E OF ROOF COVERING CITY a ZIP efirl3 EXISTING BUILT-UP ROOF ❑ LICENSE NUMBERAli ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby aHlrm that I am licensed under provisions of Chapter 5(commencing with Section WOOD SHAKES 7000)of Division 3 ol.the Business and Professions Cade,and my license is In full force and effect. 2-.2— < WOOD SHINGLES E]License Class� Lia Number - Date �✓ OTHER(SPECIFY) El OWNER-BUILDER Contractor OWNER-BUILDER DECLARATION PROPOSED hereby affirm that am exempt from the e: Any city License Lew for the following rens ZKIZ (Sec.7031.5,Business end demolish, Profeor rep Code: Any city or county which requires a permit to conlicanstruct.alter,Improve,to file signed staair anystructure,h is licenseor to issuance,see requires the BUILT-UP ROOF �( applicant for such permit to Ills a signed r 9(commencing that g le licensed pursuant to the provolone • of the Contractor's License Lew(Chapter h(commencing with om and 7000)basis for 3 of the Busexempio and violation Of Code)or that he Is exempt Therefrom and the basis for the ica t to ASPHALT SHINGLES exemption.Anyty violationo t more of than tion 7031.5 by any sapplicant($5 ).for a permit subjects the applicant to ,�,�/• e clue,as owe net more than Ove hundred doers with wage WOOD SHAKES L� ❑I,se owns of the property,or to dedemployees with wages as their Bole compensation,will s. the work,and the Contractor's Is not Intended or offered for ase(Sew owner at Business and builds o- atonvesth The Contractor'oessuch workhi snet apply ghhis own employees,pho rovide that WOOD SHINGLES improves!hereon,and who does deco work himself or through his own employees,provided!hal ❑ such improvements are not completion, leb n,or offered for Bale. ill however,the en of pr or Improvement is sold not or hin Imprne ove sr purpose sal downer-bulltlerwlll have the bureau of proving that hedid OTHER(SPECIFY) ❑ not build or Improve for purpose of eale.)- ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contrasor's License Law does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of property who builds or Improves thereon,and who contracts for such projects with a c m licensed pursuant to the Contractor's Licensee Lew. PROVIDE MFGR.INSTALLATION SPECS. ❑ emm exempt under Sec. ,B$P.C.for this reason L 0 A P , WORKER'S COMPENSATION DECLARATION owner Date AP !CATION DATE VALUATION PERMIT FEE I hereby aHlrm under penalty of perjury one of the following declaration: ❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, 3 �A Bullding ` 4� as provided for by Section 3700 of the Labor Code,for the performance of the work for which this try JJS permit is issued. Ut GVy-. SBISfnIC ❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of f_ry711tr the Labor Code,for the performance of the work for which this permit is issued.My Worker's V 'Compens n Insure ss.Farrier end Policy number are: .yam �.���. (—\� Total Carrier PolicyNwWZ7�=` PERMIT AUTHORIZATION DATE CERTIFICA E OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE . �k ^ (Tole section need not be completed it the permit is for one hundred dollars($100100 o)or less.) I certify that In the performance of the work for which this permit Is Issued,I shell not employ any person In any manner so as;to become subject to the Workers'Compensation Laws of Cell. All roofs shall be inspected prior to any roofing material being fornia. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. NOTICsubject to the WorkeTO rs'APPLICANT:Compensation n provisions ofthis thelcate of Laborr Code.you mustuforthwld become ith comply Applicant understands and will comply with all non point with such provisions or this permit shalObe deemed revoked. Source regulations. I certify that I have reed 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 All roof coverings to be class"C"or 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 hatellitles, r • j f the grpe costa and expenses which may In any way accrue against eoltl City In consequence or and l7rammg ohms permu. SIGNATURE OF APPLICANT 'DATE PRE-INSPECTION: PLYWOOD: IN-PROGRESS: INSP. DATE NSRDATE 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