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R 5757 ERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER Rss 57577 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (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 lotoSS Lok. 11o0q ��` RESIDENTIALCOMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA NAME r �'�s -� '`-'t YES ❑ It yes-I understand that roof assembly s required, Class A NO ❑ Initial I.C.B.O.# ADDRESS EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S NAME LAJNIrr N ER "A)(r C"%PtIj ' SWeL TO BE REMOVED TO BE RETAINED ADDRESS TYPE OF ROOF COVERING CITY&ZIP P'0 • 3S583 Wbf.,•se 2era•...sr CI}• EXISTING . PHONE-- _J_77— B33I BUILT-UP ROOF ❑ LICENSE (0-72,92,SNUMBER ASPHALT SHINGLES . LICENSED CONTRACTORS DECLARATION hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES n 700 0)of Division 3 of the Business and Professions Code,and my license Is In full force and effect. '"meq WOOD SHINGLES License Class `' 1 Llc.Nu ar Z' Contra ontrec tG��\'Lf9Y� OTHER(SPECIFY) ❑ OWNER the Co L License PROPOSED I hereby affirm that em exempt from the e: Any Llcenee 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 of the Contractors License Law(Chapter B(commencing with Sectlon 7000)of Division 3 of the .� Business and Prolesslons Code)or the,he Is exempt therelrom and the beep;for the alleged ASPHALT SHINGLESo e pnen.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to ❑ ©SO a civil penalty of not more than five hundred dollars($500),): '0 L as owner of the property.or my employees with wages as their able compensation,will do WOOD SHAKES ❑ the work,and the structure Is not Intended or offered for sale(Sac.7044,Business and Proles. dons Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ElImproves thereon,and who does such work himself or through his own employees,provided that such Improvemenle are not intended or offered for sale.If,however,the building or Improvement 4C) ?/I_ is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) call AzJC.tibg/4 not build or improve for purpose of sale.), S N ❑I,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 Improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS. Ownerem exempt under Sec. ,B&P.C.for this reason ownerDate WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: ❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, Building pas eprovide for by Section 3700 of the Labor Code,for the performance of the work for which this (�O^ permltl ' sued. Y J{ SeISmIC eve and will maintain Worker's Compensation Insurance.as permit by Section Worker's'of s the Labor Code,for the performance of the work for which this permit le Issued.My Workar'e 7 20 -In. Insurance carri�e^r and Policy number are: TOtflI PUNA Policy No. 44E5 orJol3fo Carrier FROM WORKERS' PERMIT AUTHORIZATION DATE CERTIFICATE EN EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.OQ (This section need not be completed If the permit Is for one hundred dollars(S700)or lees.) ,�C Ln—/ ^� I 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 roofing material being fornia. installed. If a roof is installed without first obtaining an Date Applleant inspection,I agree to remove all new materials for inspection. subject.t e Wa Workers'Compefnsation pprrcvislonls of rtelLabor Code,Exemption, mustuforthwlithbecome Comply Applicant understands and will comply with all non point with such provisions or this permit shelf be deemed revoked, source regulations. s I certify that I have read this application and state that the above Information Is correct.I agree to comply with all only and county ordinances and state laws totaling to building construction,and All roo verings be Cl Slp�or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In- 117K77��-- apeman agreesee. �Z 9�' (We)agree to save,Indemnity and keep harmless the City of Cupertino against sequelae, judgments,costa and expenses which may In any way accrue against said City In consequence of the granting of this permit. ATURE OF PPLIC DATE PRE-INSPECTION: PLYWOOD: IN-PRO SS: INSP. DATE INSP. DATE INSP. DATE TEAR OFF INSPECTION: BATTENS: FINAL: =y/ INSP." DATE INSP. DATE INSP. DATE NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY '