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R 5985OFFICE COPY PERMIT R_ 5 9 8 5 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-9228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDDRRJEISSSS/. ////.ST Jt" IAy�/��I-, y / t/ �. / RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA YES ❑If yes- I understand that a Class A t NAME LLY li-��� root assembly is required. NO ❑ Initial LC.B.O. R ADDRESS_ EXISTING ROOF COVERING �"'E— PHONE 6; / j NUMBER OF EXISTING COVERINGS TO BE REMOVED ^ TO BE RETAINED CONTRACTOR'S NAME �Q. `/-EJC `t� �7� /� ADDRESS�D Q�X .. TYPE OF ROOF COVERING / Lill, CITY & ZIP CJ / S C— C=r �� j EXISTING PHONE BUILT-UP ROOF E]ICENSE NUMBER /7L ASPHALTSHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section WOOD SHAKES 7000) of Division 3 of the Business and Professions Code, and my license le In full farce antl affect p^ C- WOOD SHINGLES ❑ License Class `� Lic. Number OTHER (SPECIFY) ❑ Date Contractor PROPOSED OWNER -BUILDER DECLARATION hereby affirm that I am exempt from the Contractors License Law for the following reason. IS7031.5, Business and Professions Code: Any city or county which requires a permit to construcapplicnt,alter,hprove,ermit demolish, eny h, or re prior loses pursuant al the the forlicensed BUILT-UP ROOF statement statement that he Is applicant for such permit to file a mentrthat he pursuant to the provquires ns of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business antl Profeselons Code) or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLEB exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).1: ❑l, as owner of the property, or my employees with wages as their sola compensation, will do WOOD SHAKES ❑ the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes. t slons Code: The Contractors License Law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or through his own employees, provided that WOOD SHINGLES ❑ such Improvements are not Intended or offered for sale. If, however, the building or Improvement Is sold within one year of completion, the owner -builder will have the burden of proving that he did OTHER (SPECIFY) ❑ not build or Improve for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sac. 7044, Business and Professions Coda: The Contractors License Law does not PROVIDE I.C.B.O. REPORT NO. apply to an owner of property who builds or Improves thereon, and who contracts for such projects with a contractor(e) licensed pursuant to the Contractors License Law. E]I am exempt under Sec. ,B a P. C. for this reason PROVIDE MFG R. INSTALLATION SPECS. Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: ❑ 1 have and will maintain a Certificate of Consent to self -Insure for Workers Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. yg�� p� A a W BDI ding ❑ have and will maintain Workers Compensation which this ea required Is Is by d. Section 3700 s ,the Labor Code, for the performance of the work for which the permit Is Issued. My We, Compa/n$s�/�taio�ns lnsurenFe ,�� q Seismic terrier en Ila numbs/(�'era: 1 7 Total cerri�s//!pi{��y_� s7��/dpiety No. Yvh PERMIT HORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' L YIJ ' COMPENSATION INSURANCE N.C.Ej (This section need not be completed If the permit Is for one hundred dollars ($100) or less.) I certify that In the performance of the work for which this permit Is Issued, I ahell not employ All roots 1 be inspected prior to any roofing eing any person In any manner so as to become subject to the WorkeraCompensation Laws of Cali. fornia. installed. It a roof is installed without first obtaining an Date Applicant inspection, I agree to remove all new materials for inspection, subject otheWorers'CompeE TO APPLICANT: fnaetlonproviafter sionisofethefocate of LaborrCode,yolumustushouecome forthwlitlhbcomply Applicant understands and will comply with all non point with such provisions or this permit shalAba deemed revoked, Source regulations. I certify that I have read this application and state that the above Information Is correctI agree to comply with all city and county ordinances and state laws relating to building construction, and All roof coverin obe class "C"or better. hereby authorize representatives of this city to anter upon the above-mentioned property for In. ePepurposes. 7 Zr-9� (W (We)) agree save. Indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs antl expenses which may In any way accrue against said City In consequence SIONAMRE OF APPLIC NT DATE Of the greening of this permit. PRE -INSPECTION: PLYWOOD: IN -PROGRESS: r 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