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R 5002 (2) PERMIT R_ 500 2 . APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED ' WITHIN 1 DAYS PERMIT ISSUANCE OR WI F DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS GlIP RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA y. VES ❑ If yes-I understand that a Class A NAME ,y roof essemby is required. NO ❑ Initial I.C.B.O.H ADDRESS— ML40 EXISTING ROOF COVERING PHONE 1 5f NUMBER OF EXISTING COVERINGS CONTRACT S - I� 1�L`A� ra SGwhGPA TO BE REMOVED TO BE RETAINED NAME — ADDRESS 22 CIN&ZIP rZ ` � _ ST IS12S TYPE OF ROOF COVERING N J 7 FX(ISTING PHONE 'S 1 1 BUILT-UP ROOF ❑ LICENSE -- /.�I� C 3� ASPHALT SHINGLES NUMBER ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES ❑ 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and effect. C-3� �c� WOOD SHINGLES (1 License CI a Lic.Number Date 2 contrector P1Md�f�4� U 12 Cn OTHER(SPECIFY) OWNER.BUILDER ECLARATION PROPOSED JUL 2 1996 I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to til I Y yr 4Ur©fY I IIVU 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 provlalane of the Contractors License Law(Chapter g(commencing with Se 7000)of Division 3 of the Business and Professions Code)or that he Is exempt therefrom Ihti heels for the alleged ASPHALT SHINGLES ❑ exemption.Any violation of Section 7031.5 by any applicant oreper cts the applicant to e civil penalty of not more than five hundred tlaltar e($500), ❑I,asowneroftheproporty,ormyemploysea withwaas th mpensation,will do WOOD SHAKES ❑ the work,and the structure Is not Intended or a to for sale( Business and Profee. alone Code:The Contractor's License Law tloe app o r of property who builds or WOOD SHINGLES Improves thereon,and who does such work htfn Ifor h own employees,provided that ❑ such Improvements are not Intended or off to ever,the building or improvement Is sold within one year of completion,the owner. ull ft the burden of proving that he did OTHER(SPECIFY) not build or improve for purpose of sale.). D I,as owner of the property,em exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Profe9alone Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO. 2013 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, PROVIDE MFGR.INSTALLATION SPECS. 01 em exempt under Sec. ,B 8 P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION .. 1 hereby affirm under penalty of perjury one of the following declaration: ;(]I have and will maintain a Certilicate of Consent to self-insure for Worker's Compensation, ..Building asprovidedI- forby Section 3700 of the Labor Code,for the performance of the work for which this © c q�i@`rXlmbflJJe lesued . Seismic / 1 have entl will maintain Workers CompenAethin Insurance,as required by Section 3700 of diere Code,for the performance of the work for which this permit le Issued.My Workers Compen�e�etlon Insurance carrier and Policy number are: Total carrier S- I -ru ic, d• Policy No.�s�-� P E R M I T;AUj H0RIII ZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE NO.O n (This section need not be completed If the permit Is for one hundred dollars($100)or lees.) —2 I certify that In the performance of the work for which this permit Is Issued,I shell not employ any person In any manner e0 as to become subject to the Wit e'C mpeneatlon Lewy of Cali. All roofs shall be inspected prior to any rooting material being fornia. p installed. If a roof is installed without first obtaining an 2 Data b Applicant inspection,I agree to remove all new materials for inspection. NOTIC TO AP (CANT: If,after making this Certificate of Exemption,you should become subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will Comply with all non point with such provisions or this permit shall be deemed revoked. Source regulations. I certify that I have read this application and elate that the above Information Is correct.I agree to comply with all city and county ordinances and state laws relating to bullding construction,and rings glass"C°or better. hereby authorize representatives of this city to enter upon the above.monlloned property for In. I'J /�7 /� //y� sit(We) purposes. [ILL/ 1 4 (We)agree s save,expenses and keep harmless wa the Clry of Cupertino against liabilities, l l( • of the gran costa and expenses which may In any way accrue against said City In coneequenca 01 the granting of this permit. 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