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R 4985 • PERMIT R_ APPLICATION FOR CITY-OF CUPERTINO NUMBER 4 9 8 5 . INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR �- _65-00_1N13 ADDRESS 180 DAYS FROM LASTCALLED INSPECTION.(� (Q 0�; W �w �,2 �/ RESIDENTIAL{J` COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA YES ❑ If yal —1 understand that a Class A NAME ^� roof assembly is required. NO ❑ Initial I.C.B.O.11 - ADDRESS !�A`414" �C/ G �l EXISTING ROOF COVERING PHONE Y Zl �� — Q NUMBER OF EXISTING COVERINGS CONTRACTOR'S NAME - (, S rn'oS jZ,00TO BE REMOVED TO BE RETAINED �✓ ADDRESS /,r 7 t7 TYPE OF ROOF COVERING _ CITY&ZIP �J 6 EXISTING PHONE c/�/ BUILT-UP ROOF LICENSE UMBER N 7 6 �' ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION r I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 00 �$ K ❑ 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and effect. ❑ License Class INGLES Llc.Number , Date Contractor - 4,F�(SPECIFY) ❑ OWNER-BUILDER DECLARATION R hereby ,Buirm that I em exempt from the e: Any city License Law for the mhos ng reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to ' construct,after.improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP F ❑ applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions • of Ile Contractors License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Profession$Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES Elexemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars(5500).): ❑I,as owner of the property,or my employee$with wages as their sole compensation,will do WOOD SHAKES ❑ the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes- sions Code:The Contractor's License Law does not apply to an owner of properly who builds or - WOOD SHINGLES Improves thereon,and who does such work himself or through his own employees,provided that ❑ 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(Sec.7044,Business and Professions Code:The Contractors License Lew 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. E] B P. PROVIDE MFGR.INSTALLATION SPECS. I am exempt under Sec. , & C.for this reason OwnerDate WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following federation: ❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, �] Buildinei as provided for by Section 3700 of the Labor Code,for the performance of the work for which this '! /'Y/ g--y�— permit isissued, 7-" 5815mIC ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 01 the Labor Code,for the performance of the work for which this permit Is Issued.My Workers Compensation Insurance carrier and Policy number are: Total Carrier Policy No. PERMIT AUTHOR1 ION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.❑ �� (Tela fy that I need th$ er r antcompleted the If the permit Is for one hunpermit is I dollasued,I($1 ll n er employ I certify that In the performance of the work for which this permit I$Issued,I shall net employ any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. TOOT^shall be inspe ed prior to any roofing material being fornia, installed. If a roof is installed without first obtaining an Data Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non ant subject to the Workers'Compensation provisions of the Labor Cotle,you must forthwith comply pP P Y p with such provisions r this permit shation deemed revoked. SOUfCe regulations. r �� 1_ I certify with all have and thirty ordinances and d te state laws aboveting to building construction,and / I//�}, mcomplythoM1ell cityanticounty ordinances antlttotelowshelallde-rkentingconsfrerty for All roof CoverIBSS' rtDe f. hereby authorize representatives of this city to enter upon the ebove.menllonetl property for In- spection purposes. - 11 (We)agree to save.Indemnify and keep harmless the City of Cupertino against liabilities, judof the granting of this perrmitments,costs and ees which may In any way accrue against sem Clry Inconsequence SIGNATURE OF APPLICANT DATE 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