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R 4902 (2) PERMITp APPLICATION FOR CITY OF CUPERTINO NUMBER R— `� O REROOF PERMIT INSPECTION'DIVISION PERMIT EXPIRATION (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED • , WITHIN DAYS PERMIT ISSUANCE OR WI DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS ///1 4•-./, ��[///� RESIDENTIAL COMMERCIAL OTHER OWNER'S - HAZARDOUS FIRE AREA YES ❑ If yes—I understand that a Class A NAME roof assembly is required. NO d Initial - LC.B.O.If ADDRESS EXISTING ROOF COVERING PHONE — 33-3 '3 NUMBER OF EXISTING COVERINGS CONTRACTOR' TO BE REMOVED—J—TO BE RETAINED NAME— ADDRESS AME ADDRESS - D / TYPE OF ROOF COVERING • CITY&Z�IP� / EXISTING PHONE`] lei —O 3(p Z►• BUILT-UP RO ❑ ✓ . LICENSE NUMBER `j' ASPHALTSHINGLE�S� LICENSED CONTRACTORS DECLARATION t-Qlu 1 hereby affirm that 1 am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license is In full force and effect. 2— :31 /�' R Date Contraor WOOD SHINGLES Ulcers Clime B `— � - Uc.Number /' `p S �Q OTHER(SPECIFY) E]ct OW from th ContUDER DECLARAT N PROPOSED hereby affirm that em exempt from the e: Any License Lew for the followingrmftreason, (Sac.7031.5,Business and demolish, or rep Code: Any city or county which requires a permit to �,\\� applicant alter,improve,to file signed statement anystructure,Is licenseor to issuance,pursuant to the the BUILT-UP ROOF r^ �� ❑ applicant for such permit a flaw a signed statement root he le licensed p 000)of to the provisions q . of the ss and Prof License Lew(Chapter a(commencing with therefrom and 7000)of for the ale the \ tS't' \$ exemption. entl violation of Code)or that he Is exempt ant for entl the bests for the ica nt to 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 live hundred dollars($500).): GeSYY�� Q ❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES 9V"� Q the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes. < ", �.- sionsCode:The Contractor's License Law dose not apply to an owner of property who builds or WOOD SHINGLES j)� ❑ 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-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ not build or Improve for purpose of sale.). EJ 1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of property who builds or improve&thereon,and who contracts far such projects with a contrector(s)licensed pursuant to the Contractors License Lew, PROVIDE MFGR:INSTALLATION SPECS. ❑1 am exempt under Sec. ,B B P.C.for this reason Owner oafs WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: G as provided for by Section 3700 of the Labor Code.for the performance of the work for which this ❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, BUIIdin g/--«—O Permit isIssued. d ,` Seismic haveantl will maintain WorkersCompensationthe work Insurance,as required by Section 37000 ,v • ' t or Code,for the pan I and of Policy work for which INS permit is lesuatl.My Workers O Compensation Inauranca rrler end Pollry number are: Total Carrier Policy No.AL= 3179" PERMIT AUTHORION DATE CERTIFICATE OPrEXEMPT10N FROM WORKERS' COMPENSATION INSURANCE N.C.p �S (This section need not be completed It the permit Is for one hundred dollars($100)or lees.) /TL I certify that in the performance of the work for which this permit is Issued.I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofs shall be inspected prior to any roofing material being fornia, installed. If a roof is installed without first obtaining an Data Applicant inspection,I agree to remove all new materials for inspection. ou shouecome subjecNOTICE tothe APPLICANT: If,WorkeraeCompensatleon provisions of thellcate of LaborCode,you musttfo thwllitthbcomply Applicant understands and will comply with all non point with such provisions or this permit shall be deemed revoked, source regulations. I certify that I have read this application and state that the above Information Is correct.I agree to hereby authoriy with ze rep and county of this ces and ter u on the bove-bulldlnp construction,and All roof CQygnnJbe4claC"Or beHBL" hereby authorize city and county of this Gley to enter upon the sing to bentlon c property for In- ////�/spection purposes. g(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, ' attha erB0l0A at IhIB PBfsole oats and nll.expenses which may In any way accrue against swarf City In consequence SIGNATURE 91F 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