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R-6622 PERMIT R_ 6622 . APPLICATION FOR _ CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR WI180 HAYS FROM LAST CALLED INSPECTION. BUILDING ADDRES (/�� /0/- VV .�...._ RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA - YES ❑ If yes-I understand that a Class A NAME - roof assembly sebly is required. NO ❑ Inkii I.C.B.O.N EXISTING ROOF COVERING PHONE O NUMBER OF EXISTING COVERINGS CONTRACT TO BE REMOVED TO BE RETAINED NAME ADDRESS Zi_ TYPE OF ROOF COVERING CITY&ZIP EXISTING PHONE�/Z � (y��l/ BUILT-UP ROOF ❑ LICENSE P ? ASPHALT SHINGL NUMBER D LICENSED CONTRACTORS DECLARATION 0 hereby iaffirmnion that am Business under lessons of Chapter a(commencing with Section WOOD SHAKES 7000)of Division 3 of the Busineea end Professions Code,and my license Is In full force and - eff Licen _4� (yea 1999 License . OOD SHINGLE UN 1999 License Claes Lid.Number Date contractor OTHER(SPECT �y ❑ OWNER-theConRDECI License p OSED I hereby eHBuirm that em exempt from the e: Any city or coup Lew for the follorequires a reason. (Sec.10315,Business and Professions Code: Any city or county which re,also a permit to construct,alter, h Improve,demolish,siorrepairenystructure,prior toIts Issuance,alsothe BUI OF ❑ applicant for such permit License floe elgnedr 9(comm that he le licensed pursuant to the provlalone of the ss an c Profstens Law(Chapter a(commencing with Section 7000)of for the 3 0l the • ex Business and violation of Code)or that he Is exempt antortherefrom and the beefs far the alleged ASPHALT LES '� exemption.Any f violation of than five 7031.5 by any applicant for a permit subjects the applicant to e civil penalty of not more then Ilva hundred dollars($500).): C]1,as owner of he property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑ the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profen Bions Code:The Contractor's License Lew 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 sale.If,however,the building or improvement Is sold within one year of completion,the owner-buitcar will have the burden of proving that he did OTHER(SPECIFY) El build or Improve for purpose of sale.). ❑I,as owner of the property,em exclusively Contracting with licensed cont rectors to construct the project(Sec.7044,Business and Professlons Code:The Contractor's License Law 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 contractor(s)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS. ❑I em exempt under Sec. ,B 8 P.C.for this reason Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: I have and will maintain a Certificate of Consent to seli-Insure for Worker's Compensation, Building as provided for by Section 3700 of the Labor Code,or the performance of the work for which this g permit Is Issued. $eISR11C [:]I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 144-74,00 y the Labor Code r the pe for anca of the work for which this permit Is Issued.My Worker's !- Comp sabo mpce Car nd Policy number are: ��//��XX�yy Total Cerrl PoIIcyNo. � PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE N.C.D ^ ^ (This section need not be completed If the permit Is for one hundred dollars($100)or lase.) Q fir( I certify that In the performance of the work for which his permit Is lssuetl, shell not employ any person In any manner so as to become subject o the Workers'Compensatmn Laws of Can. All roofs shall be inspected prior to any roofing material being fornia. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO ecome sub to the Workeres'Compensation provisions oftheilLabor Codecate of m Exemption, must forthwith Applicant understands and will comply with all non point Y PY with such provisions or this permit shell be deemed revoked. SOUfCe regulations. I certify that I have read this application and state that the above Information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and All ro f covert to be ass" "or better. /- hereby authorize representatives of his city to enter upon the above-mentioned property for In- �D�jl �C(L� herebspachy purposes.r /Y1 (We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, oIRs granting of this permit.es which may In any way accrue against said City In consequence SI ATUR O��LICAN 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 OFFICE COPY