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99110133 (2) 3 © b s- I L 7 110133 PERMIT APPLICATION FOR CITY OF CUPERTINO NUM BE INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. • BUILDING ADDRESS 1 �1sn� RESIDENTIAL COMMERCIAL OTHER OWNERS I ` . . / HAZARDOUS FIRE AREA NAME Vv� `f \IJDC4 VES ❑ Ifyess Iunderstandthat. Class root assembly is required. 1 /'1 (pY NO ❑ Initial I.C.B.O.41 ADDRESSq \ _Q1P oyoiz vii 5k- EXISTING ROOF COVERING PHONE 8 q l(� NUMBER OF EXISTING COVERINGS W CONTRACTOR'S (� y'' G NAME Uf f F—Ool�� ,J TO BE REMOVED TO BE RETAINED ADDRESS p„-7'1 !/. TYPE OF ROOF COVERING CITY&ZIrP��II//YY,,JJ`` \\ N(f� �O1i11 � ��(Z EXISTING PHONE�C`y 6L) �� ` — I�� 1 BUILT-UP ROOF LICENSE NUMBER ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I em 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 full force and affect' �_ WOOD INGLES ❑ License Class"� +�"iic.Number `�O� O ' G Date 1.1—'3 Contractor 'rr cM/ CT SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSE 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 consVuct,alter,improve,demolish,or repair any structure,prior to its issuance,step requires the BUILT-UP O applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHAL G S exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to JJ • e civil penalty of not more than live hundred dollars($500).): O` D //x ❑I,as owner of the property,or my employees with wages as their sots compensation,will do WOOD SHAKE J the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes- 1 lions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES Iy-�I� U improves thereon,and who does such work himself or through his own employees,provided that I�OV 1 9 1999 such improvements are not intentletl 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,em exclusively contracting with licensed contractors to construct the project(Sec.704q.Business and Professions Cade:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT apply to an owner of properly who builds or improves thereon,and who contracts for such projects with a contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.1 am exempt under Sec. ,B&P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby infirm under penally of perjury one of the following declaration: I_ q I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, `L � Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this L permit is issued. Fl I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of �r/I �l` Seismic the Labor Code,for the performance of the work for which this permit is issued.My Worker's L f/ J O Comp tion Insurance arria/j�antl Policy n or are: TOt Carrier t Policy No. , 0 3Z'7^0( PERMIT AUTHORIZATION DATE CERTIFICATE OF E EMPTION FROM WORKERS' COMPENSATION INSURANCE C.❑ (This section need not be completed if the permit is for one hundred dollar ($1 0)or less.) � r— I certify that In the performance of the work r w h this pe it is issued,I sh I not employ any person in any manner so as to become su ject to he War a s'Compens Ilo Laws of Cali- All roofs shall be inspected prior to any roofing material bei g fornia. installed. If a roof is installed without first obtaining an DatetcS�'1—'99 Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: It.alter making 1 errficate of Exemption,you should become 5ER s nd WIII cpm I with all non pmt .object to the Workers'Compensation provisions of the Labor Code,you must forthwith comply P Y P with such provisions or this permit shall be deemed revoked.I certify that I have read this application endstate that the above information Is correct.)agree to comply with all city and county ordinances andstate laws relating to building construction,andclashereby authorize representatives of this city to enter upon the above-mentioned property for in- sp(We) purposes.(We)agree s save,pensesiw antl keep harmless Ne City ai Cupertino against liabilities,of thegran costa and expenses which may in any way accrue against said CityICANT DATE of the granting of this permit. 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