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R 4917 (2) APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4 917 REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (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 q !� .(I}.�,� ,, \` /' �Z O �I 1 t1^'L U v RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA NAME YES ❑ If y'sassemaY s required.and Class A NO LQ� Initial I.C.B.O.g ADDRESS �� EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS a1`� CONTRACTOR' / NAME '� 1 TO BE REMOVED ` TO BE RETAINED T' ADDRESS `` TYPE OF ROOF COVERING CITY&ZIPl. .' �l5 S� !'��L2- EXISTING PHONE BUILT-UP ROOFLICENSE ❑ NUMBER 9 2,23 ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provisions of Chapter S(commencing with Section WOOD SHAKES IIFIS/ 7000)of Chilton 3 of the Business and Professions Code,and my license la In lull force and sneer. WOOD SHINGLES �� ❑ License Cleea AN_umber Z Date dM1gador r OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION '^,) 1 hereby affirm Bu that em exempt from the e: Any city License Lew for the requires s a mit to PROPOSED (Sec.7031.5,Business and Professions Cade: Any city or county which requlrea a permit to construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF JUN 1 � I�tI(tQ applicant for such permit to file a signed statement that he Is licensed pursuant to the provision, A!V ttl 'fOJU of the Contractor's License Law(Chapter B(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 CII f it- x.lJi L'�IIIIVU e civil penalty of not more than five hundred dollars($500),): ❑I,as owner of theproperty,or my employees with wages as their soie compensation,will do WOOD SHAKES ©� the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profile. alone Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES Improves thereon,and who does such work himself or through his own employees,provided that ❑ such Improvements are not Intended or offered for sate.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) [71not build or Improve for purpose of sale.). ❑1,as owner of the property,am excluslvety contracting with licensed contractors to construct the project(Sec,7044,Business and Professions Code:The Contractor's License Lew 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 contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS. ❑1 am exempt under Sec. ,B 8 P.C.for this reason Owner APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: /�� ❑1 have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, Building as provitletl for by Section 3700 of the Labor Cotle,for the performance of the work for which this a permit Is Issued. Se�Sn11C ❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of ' the Labor Code,for the performance of the work for which this permit Is Issued,My Worker's Iy/ ICJ l l '-�J Compensatl eurance carr rend Policy number are: / • / Total / g•�e Carrier Policy No. � PERMIT AUTHORIZATION DATE CERTIFICATE OF EX PTION FROM WORKERS' COMPENSATI INSURANCE N.C.0 / (This section need not be completed if the permit Is for one hundred dollar,($100)or lose.) 1 certify that In the performance of the work for which this permit le Issued,1 shall not empploy any person In any manner so as to become subject to the orkere'Compensotlon Laws of Call. All roofs a e inspected prior to any roofing material being r°rola' installed. If a roof is installed without first obtaining an Dale IZV62 Applicant - inspection,I agree to remove all new materials for inspection. NOTICE TO subject to the Workers'Compeneetion proviafter makin sionls ottheflLebocate�Codemyolu must forthwith comply come 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 state that the above Information Is correct.)agree to comply with all city and county ordinances and state Tawe relating to building construction,and All roof covert s to be clan C"or better. hereby authodie representatives of this city to enter upon the above-mentioned property for In. /S� spectlon agrposes. fx ` (We)agree to save,Indemnity end keep harmless the City of Cupertino apalnet Ilablillleb,, Iutl menta,coals end expenses which may In any way accrue against said City In consequence • of tgie granting of this perms. 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFIrF rnPV