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R 5086 PERMIT (�_ 5086 APPLICATION FOR CITY OF CUPERTINO NUMBER R- PERMIT INSPECTION DIVISION PERMn ExPIRAnoN (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR • 180 DAYS FROM LAST CALLED INSPECTION. BUIL/DING ADDRESS 57 V [ vV C / (/ RESIDENTIAL COMMERCIAL OTHER OWNER'S / HAZARDOUS FIRE AREA ✓f�/�i/yD� J VES ❑ Ifyes s Imbly istandthat. ClassA NAME A�(� /—✓ ��"//7 W _ / roof assembly is required. O Initial_ I.C.B.O.q ADDRESS ROOF 5 /MJ��r(/ EXISTING ROOF COVERING PHONE79 lt'7 NUMBER OF EXISTING COVERINGS CONTRALTO 'S ^ NAME ' _ TO BE REMOVED _ U//''Y/Ln TO BE RETAINED ADDRESSy� �� COVERING CITYBZIP yry7) �N PHONEIfY .UU BUILT-UP ROOF ❑ LICENSE NUMBER OD ASPHALT SHINGLES LICENSED CONTRACTORS DE RATION I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license le In lull force antl effect WOOD SHINGLES cS License Class Lic.Number Oeta ContractorOTHER(SPECIFY) OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractors License Lew for the following 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 al the Contractor's License Law(Chapter g(commencing with Section 7000)of Dlvlslon 3 of the • Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES Apr 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).): E]1,as owner of the property,or my employees with wages as their sola compensation,will do WOOD SHAKES the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Proles alone Code:The Contractor's 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 ❑ such Improvements are not intended or offered for sale.If,however,the building or Improvement Is sold within one year of completion,the owner-bulictr will have the burden of proving that he dirt OTHER(SPECIFY) not build or Improve for pu rposo 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 Lew does not PROVIDE I.C.B.O.REPORT NO. (�r� 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 Contractors License Lew. PROVIDE MFGR.INSTAL��� 1q9I�N SPECS. I am exempt under Sec. ,B 8 P.C.for this reason Owner ooze WORKER'S COMPENSATION DECLARATION APPLICATION DATEI VALUATION PERMIT FEE hereby affirm under penalty of penury one of the following declaration: ,q / ❑ have and will maintain a of the of Consent to et dorm a for Workers Compensation,which this (�`/p_ BUllding F permit is is for by Section 3700 o1 the Labor Code.for the performance of the work for whish this �,�A r• �� trait is issued. [f Seismic ❑ haus and will the pelrf Worker's Compensation Insurance,as required by Section Worker's 's the Labor Code,for the performance of the work for which this permit Is Issued.My Workerb Total Compensation Insurance carrier and Polley number are: Carrier Policy No. PERMITAUTHOR ATI N DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE / � (This section ossa not be completed If the permit is for one hundred dollars($100)100)o or less.) vN7a'•�L I certify that In the performance of the work for which this permit Is Iftedill I shall not employ any pensci any manner so as to become aublect hrorker!�Pafnipensallon Laws of Call. AO roofs shall be inspecte prior to any roofing material being ornle. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO subject to the Workers'Compefna,after tion proVmakinsions 01 thefthis lLabor Code.you mustufothwlithbcomply ecome 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 herob authorizely with all rep and county ordinances and ter u on the above-buildingedpropertfor All r00 C rin to be class"C"or betted`�� ^ I htam authorize city and county r thin city to enter upon the aingt n construction,property for Ira spection purposes. twat agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, judgments,coats and expenses which may In any way accrue against said City In consequence • of the granting of this permit. I6NATY-51I 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