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R-4527 (2) APPLICATION FOR CITY of cuPERnNo NUMB PERMIRR- 4527 INSPECTION DIVISION PERMIT WORK IS N REROOF PERMIT (4O$)777-322$ PERMITEXPIRESDAYS IF WORK ISS ANCESTARTEDOR WITHIN 1SF DAYS S PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS RESIDENTI COMMERCIAL OTHER OWN HAZARDOUS FIRE AREA �^_ VES ❑ If yes—f understand that a Class A NAME roof assembly is required. ��n NO Initial I.C.B.O.N ADDRESS C QIS ' "� EXISTING ROOF COVERING PHONE �qls_ 2 NUMBER OF EXISTING COVERINGS I CONTR OR'S cob" TO BE REMOVED TO BE RETAINED NAME ADDRESS y.� C/� TYPE OF ROOF COVERING TV 8 ZIP y _ EXISTING PHONE t / )Y/-11BUILT-UP ROOF LICENSE NUMBER Z 6p ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑ 7000)of Division 3 of the Business and Professionsode, my license Is in lull force and effect' WOOD SHINGLES ❑ License C ss Lic.Number OTHER(SPECIFY) ❑ Detel -BUILDS 1 W from BUILDER DE ION ) PROPOSED hereby affirm that em xempt from the Contractor's License Lew lar the following reason. (Sec.7031.5,Business and Professions Code: Any city or county whim requires e permit 10 construct.alter,Improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractors License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Coda)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 a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES ❑ C]1,as owner of the property,or my employees with wages as their sole compensation,will do 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 at property who builds or WOOD SHINGLES e' Improves thereon,and who does such work himself or through his own employees,provided that L}Jn i such Improvements are not intended or offered for sale.If,however,the building or Improvement OCTIs sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) y not build a or Improve ler purpose of sale.). �I 1 za^� I,as owner of the property,am exclusively contracting with Contractor's contractors to construct `�y the project(Sac.7044,Business and Professions Code:The Contractor's License Lew does not PROVIDE LC.B.O.REPORT NO. apply to an owner of property who builds or improves thereon,and who contracts for such projects ,,CRT Y Ut- 411Yr.. with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. 1 am exempt under Sec. ,B 8 P.C.for this reason Owner Date APPLICATION DATE VALUATION PERUW FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: ❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, BUlldl as provided for by Section 3700 at the Labor Code,for the performance of the work for which this permit is Issued. 1171-1\ (JII II ❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of / Seismi the Le Code,for the performance of thew for which JJJpppllIs permit is issued.My Workers 'CompodJesurarice_rarrlepegd Policy nu er er1 Total Caryl �-�illllli //YY\\//!!�1 ItTr//,` Pmioy No. 1 '(tel V\ PERMIT AUTHORIZATION 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 certify that In the performance of the work for which this permit Is Issued,1 shall not employ any person In ny man r ac a begome sub ct 10 me workers'Compens t n Laws of Cali- All roe e,she be nspected prior to any ro fin m t ial fornla. installed. If a roof is installed withou first o aining Date V` ppllcant inspection,I agree to remove all new materials for inspection. NO ICE App NT: If,after making this Certificate of Exemption,you shout become Applicant understands and will comply wilh�ll non point subject to the orkers'Compensation provisions of the Labor Coda,you must forthwil comply PP P Y \ P with such provisions or this permit shal0be 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 roleting to building construction,and All roof rings to be c �s"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. / c j spection purposes. (We)agree to save.Indemnify and keep harmless the City of Cupertino against liabilities. QX �.�-� •. V o the grtenting o this pe�mlt es which may In any way accrue against said City in consequence SIGNATURE OF APPLZANT 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 PERMIT R- 3902 APPLICATION FOR CITY OF CUPERTINO NUMBER REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408) 252-4505 EXT. 228 PERMIT EXPIRES IF WITHIN 180 DAYS OF PERM RK IS T NOT OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS - UILDING USE ,5 �/V RESIDENTIAL COMMERCIAL OTHER OWNER'S I1fn ��/�.,� y HAZARDOUS ROOF NAME /a- i/✓• �� c.—'/U(�' FIRE COVERING AREA CLASS _ ADDRESS /�i2. EXISTING R OF COVERING PHONE G C NUMBER OF EXISTINERINGS , CONTRACT)OR'S NAME //V�/ TO BE REMOVED TO BE RETAINED TYPE OF ROOF COVERING Coo a ZIP 'NX moH�a �t� EXISTING C� • O PHONE-272--333/ BUILT-UP ROOF LICENSE NUMBER (o Z�j ASPHALT SHINGLES WOOD SHAKES LICENSED CONTRACTORS DECLARATION I hereby affirm thstI em licensed under provisions of Chapter B Icomm - e Cin, with section 70M of Division of m•Business and Profession.code, WOOD SHINGLES and my Iiceau b I tel once mtl a1/am. License Claw Lia Number Date Contractor OTHER (SPECIFY) n r P1. .- OWNER-BUILDER DECLARATION 1 h•rabv affirm that 1 . ps from tn.Contractor's License Law for the following reason. (S«.7031su.5, Business and Professions Code: Any city PROPOSED 15 1995 or County which requires a permit to construct, alter, improve,demolish,or JUN repair any anmctua,Prior to its issuance,also requires the applicant for such BUILT-UP ROOF v Permit to file.signed suument mat he is licensed pursuant to the provisions of the Con,actor's License Lew (Ch ePear 8 (commencing with section 70001 C�lY Uf VUI'CI INU of Division 3 of me Business end Professions Code)or ma at he is exempt mers� ASPHALT SHINGLES from and the basis for the alleged enemption. Any violation of Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of not more that five hundred dollars($500).): WOOD SHAKES ❑ I, u o r of the Property, or my employees with wages their sole compensation wes ill do the work, end The structure is not intended or offered WOOD SHINGLES for..Ie (Sec. 7044, Business and Profession. .ion.cod.: Th.Contractor's Linense Law tlow not apply to an ownof propeny who builds or improves thereon, and Who d0.Such work himself or through his own employees,Provided tnet buch improvements are not intended or o9fered for sale. u, however, the OTHER (SPECIFY) uilding or improvement is sold within odeYe of completion. the owner. bulltler will neva the burden of proving th!t the rid t buil r improvenfor purpose ofsele.). PROVIDE I.C.B.O. REPORT NO. ❑ 1, as owner of the property <lu vel racting with licensed contactors to construct ma proje t IS 7 44 usiness and Professions Cod•: The Contractor's Li censeL :n to an own.,of property PROVIDE MFGR. INSTALLATION SPECS. who build. or improve. the..un, a d o c sur for Ruch projects with a Contractorls)licenced oursum[to t a C hecto:R License Law. ...❑n l am exempt unser S.C. ,B.aP.c.for this APPLICATION DATE VALUATION PERMIT FEE Owher Date WORKER$'COMPENSATION DECLARATION P —� Building Qs. 1 hereby affirm that 1 have a certificate of consent to self insure,or a car ( OD tific.te of Worker.'Cc anion Insurance,or a certified copy thereof 1Sec. /,5 /// Seismic O 3800,Lab.C.). P olicy NOU+L BIR- R CV i. v mrnyn•a Total pIcerti ed C. pv P itr impaction diviaipn. Applicant C FICAT E EMPTION FROM WORKERS' N D PERMIT AUTHORIZATION DATE COMPENSATION INSURANCE (This section need not be Completed if the permit i.for one hundred opt lets($100)Or that i f . I unify slat m me performance person of the work for which this Permit isJ��7 1 y issued, 1 )or not employ any person in any manner Rp as to became Rubjact to the Worker.'Compensation Laws o1 California. Data Applicant NOTICE TO APPLICANT: If, atter making this Certificate om f E.eption, You should become Subject to the Worker.'Compensation provisions of the Labor Cod•. You must forthwith comply with such provisions or this permit All roofsS Ctedprlortoany roofing materialbeing Sit be d«matl revoked. I certify than 1 nava read this application and state that the above informs Insta If a roof S Instal d without first obtaining an Hon h <orr.ct. I egr« ro comply with au city and county ominance.and ID eCtlOfh l eg rfl all new materialsfor inspection .,at. laws relating to building construction, and thereby eumorixe repro«- tetives of this city to enter upon the above mentioned property for inspection IW.1 apt« to cava, indemnify and keep harmless the City of Cupertino iii liabilities,judgment;costs and expenses which may inany way accm. against said City in consequence of the granting of this permit ATURE 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