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R-6670 \c� 3 PERMIT APPLICATION FOR CITY OF CUPERTINO NUIiABEIR R� 6 6 7 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (406)77]-33226 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR BUILDING ADDRESS 180 DAYS FROM LAST CALLED INSPECTION.- , ` I 6 CCG' C P 2 RESIDENTIAL COMMERCIAL OTHER OWNER'S ' HAZAIRDOUS FIRE AREA xHN��^ e \I M .YES ❑ it yes—I understand that a Class A �� NAME O . 7 1-`"�N�= �rQ I.C.'--P�� root assembly is required. NO ❑ Initial I.C.B.O.a7 ADDRESS 7�? 7U�iVQfSjjy f}-V 4CS64TiIscA EXISTING ROOF COVERING 0� � O b PHONE ( --to 3 3 Cr NUMBER OF IXISTING COVERINGS CONTRACTOR'S _ 3 .r TO BE REMOVED—/ TO BE RETAINED NAME fOU! .X F TYPE OF ROOF COVERING CITY&ZIP(0 f1 srLnL,+, C-r.SdT_ C'A ' 9J'// Z EXISTING PHONE C�?_7 3 �3/0 BUILT-UP ROOF ❑ LICENSE /© (/ .NUMBER l o EASPHLICENSED CONTRACTORS DECIARATION ' ahereby affirm that I am.licensed under provisions of Chapter a(commendr wlth Section7000)of Division 3 of Uro Business and Protesslons Code,and my license U In lull force entleffect. � 2 'Lieenea clan •� / Lk.Number ��s�/o �' 999Date 7– /Y f 9 Contract« � po�.� _ OWNER-BUILDER DECLARATION hereby affirm that I em exempt from Me Contractor's License Lew for Me foifowing reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to construct,after,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑ applicant for such permit to fib a signed statement that he is licensed pursuant to Me provisions i of the Contractors Ucense Lew(Chapter B(commencing with Section 70110)of Division 3 of Me ' 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 dull penalty of not more than INe hunched tldlars(5500).): ❑I,as Owner of the property,or my empfoyeas with wages as Meir sole compensation,will do WOOD SHAKES ❑ the work,end the structure Is not Intended or offered for sate(Sec.7044,Buslness and Proles. slops Code:The Contrecmrs Ucon,e I-aw does not apply to an owner of property who wlids or WOOD SHINGLES Improves thereon,and who does such work himself or through his own employees,provloed that El such Improvements are not Intended or offered ler sale.If,however,Me building or Improvement ' Is sale within one year of completion,the owner-Iwllder will have Me burden of proving that he did OTHER (SPECIFY) 0 not build or Improve for purpose of sale.). ❑I,as owner of the property,am exclusNely contmang with licensed contractors to construct Me project(Sao.70".Business and Professions Cee:The Contractors License Law deet not PROVIDE I.C.B.O.REPORT NO." apply to an owner of property who buids or Improves Merean,entl who central for such projects with a contractors)licensed pursuer to the contractor,License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 em exempt under Sec. ,B 6 P.C.for this reason owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penally of perjury one of the following declaration: _ ❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, 00 Bulldin as provided for by Section 3700 of tin Labor Cade,for the performance of the work for which this C, per hlelasued. �` Seismic entl will melnfeln Worker's Compensation Insurance,as required by Becton 3700 0l Qp/� ih Labor Code,for the performance of the work for which MIs permit to Issued.My Workers Compermetbn Insurance center and Policy number are: Total Carrier" I I�Q,Ae d.,� T7^LS- Poly No. 62'—30-S zOao 9 PER IT AUTHO TION DATE CERTIFICATE OF EXEMPTION FROM WORKERS" COMPENSATION INSURANCE N.o] /f (This section need not be completed It the permit Is for one hundred dollars($ 100)ar leas.) ✓\\ I cerilly that In the performance of the work for which this permit is issued,I ahell not employ any person In any manner so as to become subject to the Workers'Compsneatbn Lowe Of Cell- All r0 s shall be spected prior to any roofing material be ng fords. ins Il( alled without first obtaining an Data Applicant I pection; gree to remove all new materials for inspection. subjecttoth w rkerrs'Coompemetlo provimakinsions of the Labor Unit Certificate Code,Exemyou mu-.IortirMlh a«rply Apption,you should become licant unerstands and will comply with all non point with such provisions w this permit shelf be dammed revoked. source regulations. I certify that I have read file application and state that the above Informetlon Is correct.I agree to comply with all city and county ortllnances anis state laws relating to bullding construction,and All roof covenciastOb/QQQ��...sCCCCIass"C".or better, hereby authorize raprasantativee of this city to enter upon Me above-menl{whetl property far In- V eperWe) purposes. (Wa)agree to saw,Indemnify and keep hermlees Me Clry of Cupertino id D against Helium e, h of the ggmritinq of this perrcem,and mit. may In any way accrue against said Dry In consequence SIGNA 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 COPY