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R 4999 (2) APPLICATION FOR CITY OF CUPERTINO NUMBER PERMIT R- 4999 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 RESIDENTI LL COMMERCIAL OTHER OWNERSHAZARDOUSFIRE ARE YES If A NAME I"�� ❑ rau assembly s required. A NO ❑ Initial I.C.B.O.N ADDRESS �'K^'� EXISTING ROOF COVERING PHONE Z 2 — `8 .) NUMBER OF EXISTING COVERINGS CONTRACTOR'S � � (��,, NAME K-l%��41 C4—A4 t—F.. Y r`-tT TO BE REMOVED TO BE RETAINED ADDRESS LL I Z / _ _ e /� S� piss. .( .L TYPE OF ROOF COVERING CITY 8 ZIP /�""nCl+-CEJ �'^��7�. EXISTING PHONE LIQ��`l��—C7t0� / - BUILT-UP ROOF LICENSE NUMBER S - to C-3 ASPHALT SHINGLES ?©, g LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ���WISI ' 1996 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and 1 affect. C 3 �S1 1 _ WOOD SHINGLES License CI s Lie.Number 1�3�p (;)(Y yr urcn I 114UDate I Conlre"or l OTHER(SPECIFY) a OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I em exempt from the Contractor's License Law for the following reason. (Bac.7031.5,Business and Professions Code: Any city or county whit requires a permit to construct,alter,Improve,demolish,or repair any Structure,prior to its Issue also requires the BUILT-UP ROOF applicant for such permit to file a signed statement that he Is licensed urdu .the provisions • of the Conireaor'e License Lew(Chapter B(commencing with Sect 7000) Ion 3 of the Business and Professions Code)or that he Is exempt therefroril ih a to alleged ASPHALT SHINGLES exemption.Any violation of Section 7031.5 by any applicant far perm le he ebPlicgnt to a civil penalty of not more than five hundred dollars($500).) ❑ Cl,as owner of the property,or my employees with wag6s "1 o er,0mmpe�lon,will do WOOD SHAKES the work,and the structure IS not intended or-Us retl 1 Sol 0�4;Buslness antl Profen slons Code:The Contractor's License Law doe.not p ply t, o,per of property who builds ar WOOD SHINGLES improves thereon.and who does such work himself r u hlSown employees.provided that such Improvements are not Intended or offered for ow9ver,the building or Improvement '1 ,� L�f.,- Isaoldwithin one year ofcompletion,the own erou tlerwill It a the burden of proving that he did OTHER(SPECIFY) w L(-�l.( not build or Improve for purpose of sale.). C I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractor's 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)llcansetl pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. C I am exempt under Sec. ,B&P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE `. WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration C 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building / 4 as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g XPY,rml}le seuetl. have and will maintain Worker's Compensation Insurance,as required by Section 3700 of ( -I V V seismic Labor Code,for the performance of the work for which this permit is Issued.My Worker's Ce Insurance carrier and Policy number are: Total Carrier J' vi eL11^4Policy No.Z'65—a(LO PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.0 if the (This section need not be completed if the permit Is for one hundred dollen($100)or less.) � I certify that In the performance of the work for which this permit Is Issued,I.hall not employ any person In any manner so as to become subject to the Workers'Compensation Lew.of Celi I r00;shall be inspected prior to any roofing material being fornix. installed. If a roof is installed without first obtaining an Dare Applicant inspection,I agree to remove all new materials for inspection. subje�tothe Wo ers'C mpensa on provisions of theicate of Labor Code,you you should hwit become Applicant understands and will comply with all non point with such provisions or this permit shalC,be deemed revoked. you must forthwith comply PP P y source regulations. I certify that Ihave read this application ordinancendstatefeettheabove information Is correct. agree to hereby authorize win ell city ese county ordinances and state Iowa relating to bulltling conatr erty f,end All roof COVerI g t be CIBSS"C"Or better. herebypurr representatives of this city to enter upon the above-mentioned property for int r` sp(We) purposes. �l��q�o (We)agree to.ave,expenses and keep harmless the Clry of Cupertino Ci y n on liabilities, - / of the gran coals and expenses which may In any way accrue against ealtl Clry4n consequence �� . of the granting of 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 CnPV