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R 5992 (2) PERMIT R_ 599 2 APPLICATION FOR CITY OF CUPERTINO NUMBER 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;14I v -1)/� l ' "D 00 RESIDENTIAL i COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA `I YES ❑ If yes—I understand that a Class A NAME t v ©o J roof assembly is required. NO ❑ Initial I.C.S.O.q sn�� fi,�y} ADDRESS ` ( 1 IV� EXISTING ROOF COVERING PHONE 0409 6 —' t eW NUMBER OF EXISTING COVERINGS a CONTRACTO ` NAME '�1 I 'A"1 TO BE REMOVED TO BE RETAINED ADDRESS'IG{ Dt,Ka , f /r�r� EXISTING TYPE OF ROOF COVERING CITY&ZIP / J1/ Iclw 1� VYI�I.,V.—S, y.,�1(�_ �/ PHONE / y'^'I //�� y BUILT-UP ROOF ❑ LICENSE NUMBER ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECIARANON P A O D I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES h IKf1111 7000)of Division 3 of the Business and Profaaslo is Cotle,and my license le In full tome and effect 001 WOOD SHINGLES JUL 03 WD License Clea Llc.Number Date contractor OTHER(SPECIFY) �)IyUf ��ctE{tWe OWNER-BUILDER ECLA License PROPOSED hereby affirm that em exempt from the e: Any or county Law for the following reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to pp 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 Vdif// of the Contractor's License Law(Chapter a(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 ASPHALT SHINGLES ❑ exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to ,( e civil penalty of not mom than five bundred y employees th wage: WOOD SHAKES �. ❑I,as owner of the property,or to ded oyeee with wages as their Bole compensation,will s. (N the work,and he structure Is not intended ores not for sale(Sec.7044,Business and Prdsor atone Code:The Contractors Licence Lew dome not apply to an owner of property who builds or WOOD SHINGLES �A Improves thereon,and who doessuch work himself orthrough his own employees, mproetltent ❑ such Improvements meme are not completion, leb n,or owner for kale.ill however,the buienldingof pr or Improvement Is sold not or provne e mrpurposetof sale.). OTHER will have the burden of provingthat hedid 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(Seo.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 contmctor(s)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B 8 P.C.for this reason Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE II thereby affirm under penalty of perjury one of the following declaration: M /n permit have and wlif maintain a Certificate of Consent to self-insure for Workers Compensation, Building f. LID as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g mit le Issued. !�q❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of l5/�v 0pOva r Seismic X the Labor Code,for the performance of the work for which this permit Is Issued,My Workers Compensation Insurance carrier and Policy number are: Total Carver Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.[] (This section need not be completed If the permit Is for one hundred dot ars($100)or lees.) I certify that In the performance of the work for which this permit Is issued.I shall not employ any person In any manner so as to become subject to the Workers'Compensation Lew$of Cell- All rOD S e inspected prior to any roofing material being fornix. / installed. If a roof is installed without first obtaining an Date �/ l9 Applicant �--� inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP ply 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 state that the above Information Is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. spection purposes. � ��if 7 (We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, judgments,costa and expenses which may In any way accrue against said City In consequence at the granting of this permit. SIGNAIUREOFAPPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY