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R-5381 �iNUMB PERMIT 5381 APPLICATION FOR CITY OF CUPERTINO INSPECTION DIVISION PERMIT EXPIRATION REROOFPERMIT (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 ( 0(p8Z /10 to �-4 -pN,.q_ C,� RESIDENTIAL COMMERCIAL OTHER OWNER'S (� IHAZARDOUS FIRE AREA lr NAME J6vvyll TIN' C�tWwck YES ❑ roof assembly srequirled. Dla55A NO ❑ Initial LC.B.O.N ADDRESS EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS / CONTRACTOR'S NAME A It 3e_",BvL S ,q [yLc- TO BE REMOVED TO BE RETAINED ADDRESS 5 94 . 0 lik" S� J3� q5-111 TYPE OF ROOF COVERING CITY&ZIP 'C U, t _ EXISTING PHONE 1�!J -7 2"��[-4 S's BUILT-UP ROOF ❑ NIUMBER J8D I ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ! '/ 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and ar'r'est' (� L WOOD SHINGLES �J� License Class I Lis.Number `� 13Q0 OTHER(SPECIFY) /�❑ Date��Contractor y OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractor's License Lew for the following reason. (Seo 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 fife a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the r Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHIN exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to DT l/}. T� e dull penalty o not more than five hundred dollars with wag.): WOOD SHAKE 1� ��L ❑I,as owner of to property,or to employees with wages as c.7 sola compensation,will s. the work,and se structure Is not intended or offeredtfor said(Sec owner of Business and mods a r�-� Bions Code:The,an who License Lewdoes elf or through own employers,whobuildsor WOOD SHINGL S OCT 1 lygg7 improves tenon,end who tloen such work himself of oIf,ho his own employees,provided teat such improvements are not Intended the offered for sale. ill however,the en of pr or Improvement istbuild or year of forpurposetofSaI .owner-bulltlerwillhave the burdenofprovingthat hedid OTHER(SPECT ❑ not build or improve for purpose of sola.). ❑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.REP apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. [:]I am exempt under Sec. ,B 8 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: q E]I have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this p rmil s leauetl. Seismic have and will maintain Workers Compensation Insurance,as required by Section 3700 of - _ L r Cotle,for the performance of the work for which this permit is issued.My Worker's Total I—////—Jl�f'—`.J�— Compensation Insurance carrier and Pol+1cy number are G Carrier LL�a�Z 1 ['�.�rMhIM Policy No. IZ'O ��Cl'4o PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTIO FROM WORKERS' COMPENSATION INSURANCE N.C.[] (This section need not be completed it the permit Is for one hundred dollars($100)00)or less.) 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 Ceti- Alifil5ofs 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. NOT shoulbecome subject lo the a Worrkeras'Compens tl n prrovisionis of thelLaborr Code,cate you mustof Exemtion, ufo thwiith comply Applicant understands and will comply with all non point with such provisions or this permit shalC be deemed revoked. source regulations. I certify that 1 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 All roof coverings to be lass"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property or In- spection purposes. Z (We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, Qs_��� 17 ar a:F1 7 judgments,costs and expenses which may In any way accrue against said City In consequence -T— ot the granting of this permit. SIGNATURE OFAPPLICANT 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