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R 610611 OFFICE COPY PERMIT R_ 610 6 . 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 10 3 D B Vi FL V 1f W c RESIDENTIAL_ COMMERCIAL OTHER OWNER'S (I HAZARDOUS FIRE AREA ' - c I YES ❑ If yes — I that a Class A NAME 13RJ� Y �L< T i t ``ec, assembly is reqand roof assembly is required. NO E]Initial I.C.B.O. W ' / I •'yblL(' l• EXISTING ROOF COVERING ADDRESS r"' V LV '' Ot+-� ` NUMBER OF EXISTING COVERINGS 0WIP, / �IOr6� �, 6— PHONE TO BE REMOVED (71y1`Q CONTRACTOR'S NAME _ TO BE RETAINED ADDRESS �O ? TYPE OF ROOF COVERING CITY a SIP pS EXISTING /'7c[ PHONEC( 11% D% BUILT-UP ROOF - ❑ LICENSE NUMBER k0 /" C/ C IGS— -1 b ❑ LICENSED CONTRACTORS DECLARATION hereby I licensed affirm that em under ions of Chapter a (commencing with Section 00" ES Professions ]000) of Division 3 of the Business end Profesalone Code, and my license Is in lull force and affect. G 31 6 cOS Claes Llc. Nnntnr Se [Q_ Q 'W < ,J C§& 98 ° D THER (SPECIFY) ❑ DateLicense Data comractor � OWNER -BUILDER DECLARATION I hereby affirm that i em exempt from the Contractor's L w for the following mason. in or county (Sec, 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the BUILT-UP ROOF Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's License Lew (Chapter a (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to Is e civil penalty of not more than live hundred dollars ($500).): EJ 1, as owner of the property, or my employees with wages as their sole compensation, will do WOOD SHAKES ❑ the work, and the structure is not Intended or offered for sate (Sec. 7044, Business and Profes. slons Code: The Contractors License Lew does not apply to an owner of property who builds or thereon, and who does ouch work himself or Ih rough his own employees, provided that WOODSHINGLES El such Improvements era not Intended or offered for sale. If, however, the building or Improvement - Issoldwithlnoneyeerolcompletlon, the ownerbullderwill have the burden61proving that hedid OTHER (SPECIFY) El build or Improve for purpose of sale.). ❑ I, as owner of the property, em exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Cada: The Contractors 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 am exempt under Sec. ,B 8 P. C. for this reason PROVIDE MFGR. INSTALLATION $PFOB. 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 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 thle / © �- �� ( Building permit is Issued. `/ 6 Seismic / A ❑ have and will maintain Compensation Insurance, as required by Section 3700 of L' the labor Code, for the performance of the work for which this permit is issued. My Workers performance the work � Compensation Insurance carrier and Policy number are: Total r/ L Carrier Policy No.PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' - COMPENSATION INSURANCE N.C. (This section need not be completed If the permit Is for one hundred dollars ($100) or less.) I cantly that in the performance of the work for whit his permit Is les d, I sh II not employ any person In any manner so as to becomo subject 10 orkers' camp sale Laws of call. All roofs shall be inspected prior to any roofing materia being fornix. installed. If a roof is installed without first obtaining an Date Applicant inspection, I agree to remove all new materials for inspection. NOTI E to APPLIC NT: If, altar making this Certificate Exemption, you should ammo subject to the Workers' Compensation provisions of the Lab r Cotle, you must forthwith comply Applicant understands and will tom ply with all non point with such provisions or this permit shall be doomed 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 construction, and All roof s to be c SS "Ci Or better. hereby authorize representatives of this city to anter upon the above-mentioned property for In. spection purposes. (We) agree to save, Indemnity and keep harmless the CIN of Cupertino against Ilabilitlee, judgments, costs and expenses which may In any way accrue against said City In consequence SIGNATURE O APPLICANT DATE of the granting of this permit. PRE -INSPECTION: PLYWOOD: -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