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R-6244 PERMIT R_ 6 2 4 4 . APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXP.IRATION REROOF PERMIT (408)777-3228 PERMIT EXMRES IF WORK IS NOT STARTED WITHIN 160 DAYS OF PERMIT ISSUANCE OR 1BO DAYS FROM LAST GALLED INSPECTION. BUILDING ADDRESS aJm .RESIDENTIAL COMMERCIAL OTHER OWNER'S - "" - HAZARDOUS FIRE AREA ((//���1� YES ❑ It yes-I underttand that a Class A sJ NAME _b�� NO. ❑ roof assembly is required.Initial I.C.B.O. Ji- ADDRESSn�4.rr'�.`� EXISTING ROOF COVERING PHONE NSA/ O - NUMBER OF EXISTING COVERINGS CONTRACTO / NAME f �-AM- L' TO BE REMOVED TOB EfAll lw� PF RQQf COVE CITY&Z P� , a• lADDRESS 'l�.�J�.�@.9�Sb n MAY 'EXISTING - 1999 'PHONE�SIOO) 79`/x- ! ! O Z� - BUILT-UPR , .❑ . r .. LICENSEp, .NUMBER ! b O ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION _ I hereby affirm met I am licensed under provisions of Chapter 9(commencing with Senlon WOOD SHAKES 7000)of Divalon 3 of the Buslneee end Proleselons Code,and rry,license Is In lull force and affect' WOOD SHINGLES License Cl Uc.Number e El Date Contractor OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED k Crl I hereby adtrm that I em exempt from the Contractors License Law for the folbwkg reason. (Sec.7031.5,Business and Proletarians rep Cafe: Any city or county swua requires also a requires to caneMxa ar ,Improve,d file a signed n raper any structure,Is Ic to Its)nuance,alsooeprvI ins BUILT-UP ROOF ❑ applicant for etch permit to Hie a 61gnpt statement that g lehcen to pursuant to Me prwlof the of the ss and Limon Lew(Chapter B(commending with Section 7000)al,Melon 3 of the aInampss antl Pro teflon f Cede)or that he Is exempt therefrom and the baste for me elanalleged ASPHALT SHINGLES exemption.Arty violation d h allon 7031.5 by any s($5 ant fora permit subjects the applicant to a chit penalty of not more Men INa huMred dollars(5500).): ❑I,as owner of the praperry,or my employees with wages as their We compensation,will do WOOD SHAKES ❑ the work,and the structure is not Intenaed or offered for sale(Sec.7044,Bualneaa and Pact". alone Cade:The Contractors License Lew does not apply to an owner of property who builds or WOOD SHINGLES ❑ Improves thereon,amid wits does such work himself or through h1a own amp"",provided that such Improvements are not Intended or offered for Bele.II,however,the Wlldtrg or Improvement la sold with one year of compbtkrn,Me carer- ulder will hese the burden of proving that he did OTHER(SPECIFY) E]not bulld or Improve for purpose of sale.). ❑I,es owner of the progeny,am mcluslvoly,contracting with licensed contractors to conatmct the project(Sec:7044,Buslnem end Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. appy to an owner of property who builds,or improvee thereon,and who contracts for such projects with a contractor(s)Hcensed pursuant to the Canaadors Ocenm Law. PROVIDE MFGR:INSTALLATION SPECS. ❑1 am exempt under Sec. ,B&P.C.for INs reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty,of perjury we of Me tallowing deUaratlon: 7 t have and will maintain a CanHkete of Consent to self-insure for Workers Compensation, Building 21 as provided lar try Sidon 3700 of the Labor Code,for the performerxa of Me work for which this p g perm leeued. y�44 �� �� $eISmIC • • 0 end will maintain Workers Compensation Insurance,as required by Section 37W of 4b—or Code,for the performance of the work for which We permit Is Issued.My Worker• Companm Insurance cand Pol t; icy number are: � ♦ s Total Center PdIcy3jil 9�lj PERMIT AUTHORIZATION D CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE 100)o Ion (This section need ne rtst be completed H the permit le for onuntlre0 dollars($100)or e.) l I certify Met In the performance of the work for which this permit Is Issued,I shall not employ any Penson In an manner w as to become subject to the Wo are'Compensation Laws of Cell- All roofs shall be inspected prior to any roofing material being foals. installed. If a roof is installed without first obtaining an Date J5 b Applicant , inspection,I agree to remove all new materials for inspection. NOTICE APPLICANT: If,ever madding this Cer-0ficalK of Exemption,you should become applicant understands and will comply with all non point subject to Me Workers'Comperuetlan prdvleldnn of the Labor Coca,you must fonhwlth comply with such proviso a or this pamHt shall be deemed revoked, source regulations. 1 cenNy that I have reed thU application and state Met the above Informed"le conecln agree to comply with aH city onto county ordinances,and state laws missing to bullding constmdlon,and All roof co rin be ccll(s//$n�$— �e better. /pQ seraby ausiwrfse reI><menatMs of thle ctty to enter upon the ebwe mentioned property for In T/�+ �f�L 17 apectlon purposes. (We)agrae a save,Indemnity and keep harmlem the City of Cupertino apemet Ilabllliles, ludgmena,casts and expenses which may In any way accrue agelnst sad City In consequence $Ka` ATUR F APPLICANT DATE © of a granting of MIa persalt. 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 '