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99110128 9Q // 0iz � PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBE INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 150 DAYS OF PERMIT ISSUANCE OR 100 DAYS FROM LAST CALLED INSPECTION. • BUILDING ADDRESS RESIDENTIAL COMMERCIAL OTHER OWNER'S j( x�{��\\// ,/^{...�,,) HAZARDOUS FIRE AREA NAME 1 1ZF\A)©Cd ' 1 r �� YES ❑ If yeas I assembly is eq that. Class A roof assembly Is understand that l J NO ❑ Initial I.C.B.O.M ADDRESS qT o1\QQ,1.UOt & ST EXISTING ROOF COVERING PHONE 0 ( Z NUMBER OF EXISTING COVERINGS Z CONTRACTOR'S l �(�J//�\��[' ,r\�I NAME SF�AI\�-*, a00 l vi SVSJC � TO BE REMOVED TO BE RETAINED ADDRESS �. J1 TYPE OF ROOF COVERING clTYszip _ EXISTING PHONE L( �7I I�1� BUILT-UP ROOF LICENSE NUMBER ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed untler 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 effect. r 9y� ^ .�9 WOOD SHIN ❑ License Class� �� }y �'Lic.Number S'o W `nD C Data �' 3)—b�U Contractor LLMr—�.U\'1 TIf>1''\^S' OTHER(SPE ) OWNER.BUILDERDECLARAmr�r-7—�— PROPOSED 4L I hereby affirm that I am exempt from the Contractors License Los for the following reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to gel 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 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 ASPHALT SHINGLES exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to j\ a civil penalty of not more man five hundred dollars($500).): C]1. SHAKES \ I,as owner of the property,or my employees with wages as their sole compensation,will do D the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes- sions Cotle:The Contractor's 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 NOV 91999 such improvements are not intended 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,am exclusively 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.I F RT NO. apply to an owner of property who builds or improves thereon,and who contracts for such projects •'l with a conbactor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑I am exempt under Sec, ,B 8 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: 1 n ❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, 1 `-� 1q— �(� C4 t c Do Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this l permit is issued. ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic the Labor Code,for the performance of the work for which this permit Is issued.My Worker'st on Insurance c rrior Z� ©-` S Total /(.L Compensand Policy number are: 4t1'G{q�( I .J �^�n/ �`�'�^ Carrier Policy NoVOC I 663211)[ PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' ^ COMPENSATION INSURANCE N.C.I] \ Q (This section need not be completed if the permit is for one hun eVd Ilars($100)or less.) certify that in the performance of the or r which this perm) is Issue shell not employ any person in any manner so as to beco a subl of to the orkers' ompe alien Law of tali- All roofs shall be inspected prior to any roofing material bei6g forma. installed. If a roof is installed without first obtaining an Dal.I1-19—C C} Applican inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become ORE tom I Wllh all non Olnt subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply P Y Pwith such provisions or this permit shall be deemed revoked.I certify that I have read this application antl state that the above information is correct.I agree to comply with all city antl county ordinances and Slate laws relating to building construction,andOr better. hereby authorize representatives of this city to enter upon the above-mentioned property for in- spection purposes. (We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, judgments,costs and expenses which may in any way accrue against said City..,consequence SIGNATURE OF APPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY