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99090150 (2) , . 3 ' © x9 Z °l°� b6 . PERMIT APPLICATION FOR CITY OF CUPERTINo NUMBER " INSPECTION DIVISION PERMIT EXPIRATION ,.a REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED . WITHIN IN DAYS S PERMIT ISSUANCE I OR WI DAYS FROM LASE CALLED INSPECTION. BUILDING ADDRESS,�D J �rw/`�'�I,.✓��L/�a RESIDENTIALA 'COMMERCIAL 1 OTHER - OWNERS - - HAZARDOUS FIRE AREA ' VES yes_ ., ❑ If asI understand that a Class A NAME l�s�.V roof assembly is,required. - - NO ElInitial LC.B.O.N ADDRESS EXISTING ROOF COVERING NUMBER OF EXISTING COVERINGS PHONE / CONTRACTOR'S NAME S /�T g - TO BE REMOVED L - TO BE RETAINED / .. ADDRESSO�O 7 ��/ pC�,a 1 TYPE OF ROOF iN CITY&ZIP L LV9'Ci�W !�J✓47 . / EXISTING /�/ PHONE BUILT-UP ROOF 0, y9 NUMBER 3X ( ASPHALT SHINGLES ❑ LI ENSED CONTRACTORS DECLARATION I 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 is In lull force and -effect. nQ _3 WOOD SHINGLES El' License Cl ees 01.6 Uc.Number ✓ " Date p O0 Contractor • OTHER(SPECIFY) . ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractors License Law for.the following reason. - - - (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 - ❑ applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's License LawChapter 9(commencing with Section 7000)of Division 3 of the ' Business entl Prafeaeione Cotle 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 - e civil penalty of not more than five hundred dollars($500).): ❑I,as owner of the property,or my employees with wages as their able compensation,will do WOOD SHAKES ❑ the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles. sions Cotle:The Contractors License Law does not apply to an owner of property who builds of I 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 '' N Is sold within one year of completion,the owner-builder will have the burden of proving that he and OTHER(SPECIFY) not build or Improve for purpose of sale.). ❑I.as owner of the property.em exclusively contracting with licensed contractors to construct the project(Sec.704,Business and Professions Code:The Conlrabtoes 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 Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS. ❑1 am exempt under Sec. ,B a P.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 declaration: ❑1have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Ila Building es provided Mr by Section 3700 of the Labor Code,for the performance of the work for which this o a Per lis Iseuetl. / 1"h s Seismic have antl will maintain Worker's Compensation Insurance,as required by Section 3700 of -1 bar Code,for the performance of the work for which this permit is Issued.My Worker's Campensaaon^Incu�r e�c rrer antl licyn mbar are: -fra �/a"��� Total Carrier ! Policy No.�gAfa06 PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.I] (This section need not be complated If the permit Is for one hundred dollars($100)or leas.) - t I certify that In the performance of the work for which this permit Is Issued,I shell not employ any person In y men or so as to become subject Io t orkers'Comp nsancn Lowe of can- All roofs shall be inspected prior to any roofing material being forma. installed. If a roof is installed without first obtaining an Date 7Applicant inspection,I agree to remove all new materials for inspection. NC C TO APPLICANT: If,after making this Cardiff^ a of Exemption,you should become Applicant understands and will comply with all non subject to the Workers'Compensation provisions of the ebor Code,you must forthwith comply p y point with such provisions or this permit shallibe deemed revoked. SOUICa regulations. I�t Mva'(�pg4plgagpp@ntl state that the abovenformedoto �la eonebl.l agree i to .;.. odrvti®a'6}d5n(((0espaTTTe(lyI a ter u on the above-mentioned cd property for and All roof covert be Cl r better. / here y autho ze repress led 1 h e t soler upon the above-mentionetl property for In. spectonpurposes. (j lWe)egma to save,Indemnity es w and keep harmless the Cita of Cupertino against eq uencelilm, / '1 7/? of t menta,coete and expenses which may In any way accrue against said City In consequence of tRe grenung of this permit. SIGNATURE O- PPLICANT . 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 -