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R-5434 APPLICATION FOR CITY of CUPERTINO NUMB PERMRR- 5434 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 100 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS 10158 RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA 74L.Shp_ Sreeha�Sha� YES LJItyes—Iunderstandthata ClassA NAME /'roof assembly is required. �CC© / NO 4 Initial I.C.B.O.11 ADDRESS /01619 a&SS �` Qe•ems EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACT R'STO BE REMOVED_ TO BE RETAINED. NAME O 0-a.l - P&C, 2DCV,nIq ADDRESS�' n -` I_• TYPE OF ROOF COVERING CJ� 7J CITv a zl /� Q — ,y/ EXISTING PHONE L o v �/� ` D BUILT-UP ROOF ❑ \L, LICENSE NUMBER /„ /_�/„ ASPHALT SHINGLES ❑ �!R? u� CIJ �.v LICENSEDdunderCONTRACTORSsof Chapter 9(N hereby affirm that em Business licensed under provisions of Chapter B(commencing calif Section WOOD SHAKES V 7000)o/Division 3 0l the Business antl Professions Code,and my license Is In full tome and p effect. E] 9 j� WOOD SHINGLES Dcens Cis 1Number u Dela comrecm OTHER(SPECIFY) ❑ OWNER-the Conn DECLARATION PROPOS CETA 7M D hereby affirm Bu inlet em exempt from the Contractor's License Lew for the following res (Sec.70315.Business and Professions Code: Any city or county which requires a permit to ' construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT- P" FT ❑ applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions UV llv 1 6 1997 of the Contractor's License Law(Chapter 0(commencing with Section 7000)of Division 3 of the . Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPH LT 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).1: C]1.as owner of the property,or my employees with wages as their Sole compensation,will do WOO the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes- sions Code:The Contractors 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-builder will have the burden of proving that he did OTHER(SPECIFY) not build or improve for purpose of sale.). ❑I,as owner of the property,em exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE LC.B.O.REPORT NO. apply to an owner of property who bul Ids or improves thereon,and who contracts for such projects with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B&P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: (8 7 1 have and will maintain a Certificate of Consent to selbinsure for Worker's Compensation, I Building es provided for by Section 3700 of the Labor Code,for the performance of the work for which this / permit l Iasaea. (�1 Q7 17J/ Seismic have and will maintain Worker's Compensation Insurance,as required by Section 3700 0l ((( __// 1 e L or Code,for the performance of the work for which this permit Is Issued,My Worker's Compeer n Insu e�c and Poll number are: ql/J Total Carr. Pots N . PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION the ON INSURANCE N.G� Ices fy that I need not be completed if the permit Is for one hundred dollars S1 00)or Iaeao �•(`// I certify that Ina performance o1 the work for which this permit is Issued,I shall not employ any parson in am mmanner ao as to bepome aablact to me workers companaation Lawe of call- 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. NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become A Ilcant understands and will com I with SII non Olnt subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y P 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 comply with all city and county ordinances and state laws relating to building construction,and A roof coverings to be class"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In- spection purposes. (We)agree to save.Indemnify and keep harmless the City of Cupertino against Ilabllitles, judgments,costs and expenses which may in any way accrue against said City In consequence GNATU OF APPLICANT DATE A97 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