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R-5802 PERMIT R_ APPLICATION FOR CITY OF CUPERTINO NUMBER 580 2 INSPECTION DIVISION PERMIT EXPIRATION 7 REROOF PERMIT (408)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. ' BUILDING ADDRESS ,f' RESIDENTIAL 'IZ COMMERCIAL OTHER OWNER'S L-_a HAZARDOUS FIRE AREA NAME—! /!FIJI YES ❑ If yeas assembly is andreq that. Class A (!�"'�� roof assembly is required. NO ❑ Initial— I.C.8.0.N ADDRESS �n�F�' L%�m-1 �'�%`e�L�/1, EXISTING ROOF COWERING PHONE NUMBER OF EXISTING COVERINGS kii—I CONTRACTO NAME:M �Jr,.,J TO BE REMOVED TO BE RETAINED L� r/7 ADDRESS /� / �/"� /rte, TYPE OF ROOF COVERING CITY&ZIP! ie Ao �7p/ylson.J"!—/ /�s�A0�7� EXISTING PHONE BUILT-UP ROOF ❑ NIUMBER 2 ASPHALTSHINGLES [ LICENSED CONTRACTORS DECLARATION hereby affirm that I em licensed under fessiprovisions of Chapter O(commencing wllf Section WOOD SHAKES ]000)of Division 3 of the Business and Professions Code,and my license is in full lone antl effect. , Z� WOOD SHINGLES El LkenClass Uc.Number , ,�! Date .L2�' f ContractorRp/�� /� OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractor's License Law for the fallowing reason. (Sec.7031.5,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-UP ROOF ❑ applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors License Lew(Chapter g(commencing with Section 7000)of Division 3 of the DL� t >r� Business and Professions Codi or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLE I<-L� i Li exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to e civil penalty of not more than five hundred dollars($500).): I� I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES DECq2 ,997 the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes- sions Code:The Contractors License Law 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 BV: such Improvements are not does such or offered ler sale.It,ugh his o the building s,Improvement 1J 11 Is sold within one year of completion,the owner-builder will have the bu rden at proving that he did OTHER(SPECIFY) not build or Improve for purpose of sale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions 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 contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,e 8 P.C.for this reason Owner oats WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE A I hereby affirm under penalty of perjury one of the following declaration: ` a�p :� Ov 0 / 7 I]I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Ia 7 r7 G Building O r as provided for by Section 3700 of the Labor Code,for the performance of the work for which this //''rr�� permit is issued. Seismic - = [-]I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Leber Code,far the performance of the work for which this permit Is Issued.My Worker's Compensation Insurance carrier and Policy number are: Total /67 ,60 Carrier Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.❑ (This section need not be completed If the permit is for one hundred dollars($100)or less.) a `© Z- 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 Cali- All roots shall be inspected prior to any rooding material being fornia. installed. If a root is installed without first obtaining an Date Tj�,q 7 Appilcant doi — inspection,I agree to remove all new materials for inspection. NOTscome subecct llo Ehe WorkersTO 'Compei,after nsatic prolvisionis of theicate of Labor Coda,you Mustushofort hwit�omply 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 some Information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better. hereby authorize representatives of this city to anter upon the above-mentioned property for in- spection purposes. (We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, judgments,costs and expanses which may in any way accrue against said City in consequence ofthegrantingofthispermit. SIGNATURE OF 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY