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R 6339 PERMIT R_ APPLICATION FOR CITY OF CUPERTINo NUMBER 6339 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS n I N T!)0bO W Q, RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA L ` 1 Q /"r"LL /qP_1) YES ❑ II as—I understand that a Class A NAME U roof assembly Is required. /� NO ❑' Inuial I.C.B.O.# ADDRESS /2-777 {,Z S�-'0(,- S V� r`-g , ��V EXISTING ROOF COVERING PHONE SSI l I NUMBER OF EXISTING COVERINGS / CONTRACTOR'S (� NAME AAj7�&w R00 r '�.l lL�'✓ TO BE REMOVED____X_TO BE RETAINED ADDRESSc3sis�/ TYPE OF ROOF COVERING PU a0 X 'i P J J .CITY 8 ZIP— ! EXISTING 2(os-SI y7 PHONE BUILT-UP ROOF ❑ NUMBER OI�" 3 ASPHALT SHINGLES ❑ LICENSED CON TRACTORS DECLARATION I hereby affirm that am Ilcensed under provisions of Chapter 0(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and effect' sc� WOOD SHINGLES ❑ License Gleas Llc.Number I /J/��� � Date �Z Y"4i' Cont actor�T If f L tt c P/t�. OTHER(SPECIFY) OWNER-BUILDER DECLARATION PROPOSED 1 hereby affirm that I am exempt from the Contractor's License Lew for the following reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to construct,altar,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑ applicant for such permit to fila a signed statement that he Is licensed pursuant to the provisions of the Contractor's License Law(Chapter 0(commencing with Section 7000)of Division 3 of the c/ • 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 a civil penalty of not more than five hundred dollars($500),): p WOOD SHAKES ❑ C]1,as owner of the property,or rtrtryry aNWoyaes et e1 sole com ensation,will do the work,end the structu arricy lnTerTtlep'or offered LL'rr sale 44,Business and Profes- R slops Coda:The Contraclorblicar w'ddae not aRp to an r of property who builds or WOOD SHINGLES ❑ improves thereon,antl who�o�s suc orkn elf or ihrbugh h employees,provided that such Improvements are has Intended or offered for sale.ll,howe ++r, building or Improvement Is sold within one year of c4nipljatlon,the owner-b derwi(L yvetila If of proving that he did OTHER(SPECIFY) ❑ not build or improve for pulpose of stain � UJJ``�, I ❑I,as owner of the propperty,am•exelualvell contra brg with ii d contractors to construct the project(Sec.7044,Bu9lness and Professions Code:The Con t r'6 License Law does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of proper no builds or improves thereon,and who ntracts for such projects with a conbactor(a)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS, ❑1 am exempt under S .^ B 6 P.C.for this reason u Owner 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 self-insure for Worker's Compensation, Building2'- as provided for by Section 3700 of the Labor Code,for the performance of the work for which this par t tied. have aveand will maintain Worker's Compensation Insurance,as required by Section 3700 0l Seismic the a or Coda,for the performance of the work for which this permit Is Issued,My Worker's 12- 7.90 Compensation Insurance carrier and Policy eumber are: Total Carrier�l F-UN �J Policy No.D i o60'2 -S—)� PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE 'N.CQ (This section need not be completed If the permit Is for one hundred dollars($100)or less.) 1 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 to the Workers'Compensation 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 APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y with such provisions or this permit shaffbe deemed revoked. source regulations. I certify that I have reed this application and stele that the above Information Is correct.I agree Qy�/ to comply with all city and county ordinances and state laws relating to building construction,and All roof co gs to be class's or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. � p� � We) sP purposes. .4 . • x ' 7 Z—e—,; (We)aurae to save,Intlemnlly antl keep harmless the City of Cupertino against Ilabllltlea, judgments,costa and expanses which may In any way accrue against said City in 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY.