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R 4687 APPLICATION FOR CITY OF CUPERTINO NUMBER R— 4687 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR BUILDING ADDRESS 180 DAYS FROM LAST CALLED INSPECTION. CF/ fi/ RESIDENTIAL COMMERCIAL OTHER OWNER'S � ✓ //l HAZARDOUS FIRE AREA NAME Zo, .v YES ❑ yes—Iu= �utnb . Close No EXISTING ROOF COVERINGe.o.s ADDRESS C//O ���e ��?�C�/N � �a"�+�� / PHONE s -- NU BER OF EXISTING COVERINGS CONTRACTOR'S NAME TO BE REMOVED�TO BE RETAINED �CGr//T��)rl✓� - ADDRESs n q /�C�/� ��e TYPE OF ROOF COVERING CITY&ZIP oma/ EXISTING PHONE U ^ © b BUILT-UP ROOF P G❑ NUMBER — b ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION r s 7 x; I hereby affirm that 1 em licensed oder Professions loss of Chapter y(commencing with Sectionnd WOOD SHAKES- /7;of Division 3 the Business end Professlona Coe,end my license Is In full force end (J ' Licenoffecse /°I WOOD SHINGLES Llcenee Claes� Llc.Number1-7 (� / OTHER(SPECIFY) ElDate / Contreetor OWNER-BUILDER DECLARATI PROPOSED I hereby affirm that I am exempt from the Contractor's Llc Lew for the following reason. (Sec.7031.5,Business and Proleeelona Cotle: Any city or ounty which requires a permit to construct,alter,Improve,demolish,or repelrany stru a,prior to Its Issuance,also requires the BUILT-UP ROOF ❑ applicant for such permit to file a signed statement th s'll neetl pureuent to the provisions at the Contractor's License Lew(Chapter B(c men p Ilh S Ion 7000)of Division 3 of the Business and Professions Code)or that he Is axe lllp h e)ra end the basis for the alleged ASPHALT SHINGLES ❑ exemption.Any violation of Section 7031.5 by ay`appllc r e permit subjects the applicant to e civil penalty of not more than five hundredr fere($5 01,as owner of the property,or my.SKPIay e e ea a their able compensation,will do WOOD SHAKES ❑ the work,and in structure Is not I anded or . A(e Eec.7044,Business and Profee- alone Code:The Control.,'e as Lew a a ply to an owner of property who builds or WOOD SHINGLES ❑ Improves thereon,entl who s4uch or through his own employees,provided that such Improvements ere not II do Vp edfor eels.If,however,the building or Improvement Is soltl wlinin one yeerof co(nple ,Ihja nor-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ not bulltl or Improve for pLrpo of a.). ❑I,as owner f thepropaettyy,,em exclusively contracting with licensed contractors to construct G. the project(Sec.7044,Sup fness entl Professions Code:The Contractor's License Lew does not PROVIDE I.C.B.O.REPORT NO. C / 3 epplytoenownerofrogerty,who builds or Improves thereon,and who contracts for such projects with a contractor(s) ogneed pureuem to me Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS. ❑1 em exempt'e r Sec. ,B 8 P.C.for this reason Owner Date APPLICATION DATE VALUATION P I WORKER'S COMPENSATION DECLARATION TFff I hereby affirm under penalty of perjury one of the following declaration: ❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Bulldl as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit Is leeuetl. '/�� 7L, G Seismic ❑ have and will maintain Worker's Compensation which this as squired by Section 3700 of ,the Labor Cotle,for the performance of the work for which Ihle permit Is leeuetl.My Worker's / CompensatlPoll number r}o lf 1 Total carter nma PokwN�(�rti wPERMITAUTHORIZA DATE CERTIFICATE OF MPTION FROM WORKERS' DOM ENS ION INSURANCE N.CQ (This section need not be completed If the permit is for one hundred dollars(S100)or lase.) I certify that In the performance of the work for which this permit Is Issued,I shell not employ any.person In any manner so as to become subject (he Workers'C mpensetlon Laws of nn" Ofs ShB I Sp cted prl t0 any roof) g ma rlal beihg fornla' �/- installed. I a ro f i stalled wi first obtaining an Date / 41111N Applicant inspection,I agree', remov new materials for inspection. NOTICE after sliutlb subject to the Workers'Compensation provisions of theL Code,you Exemption, forthwith comply Applicant understands and will comply with all non point with such provisions or this permit shale be deemed revoked. SO regulations. I cerefy that I have reed this application end state that the above information Is correct.I agree to comply with all city and county ordinances and state laws relating to building cbnsirualion,end Iroof m 1I Sto be 'ea C" (better. hereby authorize representatives of this city to enter upon the above-mentionetl property for In. spection purposes. GJ (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, of the granting of this permitdgments,costs and ee which may In any way accrue against said City In consequence SIGNATUtqaPnF5PLICANT 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 _