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R 5744 APPLICATION FOR CITY OF CUPERTINO NUMBER R-. 574 4 INSPECTION DIVISION PERMIT EXPIR REROOF PERMIT ATION (408)777-'3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS /0/00 Mkirm A Us 9WIA 63 RESIDENTIAL WC MMERCIAL ER OWNERS / 11 I HAZARDOUS FIRE AREA ' NAME V SA \ e5A3 5' L r(Ac,1 l QA VES ❑ If yes-I assembly is that. Class A �" roof assembly is required. NO Initial I.C.B.O.e ADDRESS 30 �. lSn7G S + �� Ule(n7 EXISTING ROOF COVERING PHONE g 3 3 O NUMBER OF EXISTING COVERINGS t CONTRACTOR'S 1 p NAME ©ll 19(A&J_k TO BE REMOVED S TO BE RETAINED ADDRESS % c LYPE OF ROOF COVERING CITY&ZIP u EXISTING PHONE Y� '36Z. I I ( BUILT-UP ROOF ❑ . LICENSE NUMBER62.7-731 ASPHALTSHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is in lull force and effect. WOOD SHINGLES ❑ License Class�� LIc.Number 7• ' ❑ Data Contractor G J OTHER(SPECIFY) OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractor's License Law 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 fila a signed statement that he is licensed pursuant to the provisions of the Contractor's License Lew(Chapter I(commencing with Section 70001 of Division 3 at the Business and Professions Coda)or that he is exempt therefrom and the bash;for the alleged ASPHALT 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,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 Profes- sionsCode: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 ' 1 �` -{ I/ �j 1 such improve men tsarsn omplIntended oro owneror-builder will however,the burden he lding of pros Improvement OTHER SPECIFY U.S, 11k rro SIM n sold build I Dna year of purpose s the owner-bulltler will have the burden of proving that he dltl not builtl or Improve for purpose of sale.). (SPECIFY) 0 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. 35Z apply to an owner of property who builds or Improves thereon,and who contracts for such projects with a contractogs)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B&P.C.for this reason Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE ' I hereby affirm under penalty of perjury one of the following declaration: ❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, B W Idln6 as provided for by Section 3700 of the Labor Code,for the performance of the work for which this PAID ® 1 permit Ki�aieaued. P9 SBISmjC IV„or Cad will the performance Worker's f the work for which ce,this as required by Section Work 0l the Labor Cotle,for the pedormance of the work for which this permit Is Issued.My Worker' p C Compensation Insurance carrier and Policy number are: OLy S Zor A 1 3 AM r J Total cardar4o- 1pt)iyi C.0 Policy No`x( PERMITAUTHORIZA ION DATE �—CERTIFICATE OF EXEMPTION FROM WORKERS' n I' COMPENSATION INSURANCE N.C.i] V'yy' r v C 1 I V (This section need not be completed If the permit Is for one hundred dollars($100)or leas.) 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 Can- All roofs shall be Inspected prior to any roc ing mat hal being total., installed. If a r f is installed without first obtaining an DateApplicant �Q/•/X�.✓ti- inspecticFa,(i� Xto remove all new materials for inspection. NOTICE a APPLICANT: a ;her making ihl f the Labe of Exemption,you should become Applicant understA band will comply with all non point ;object to the Workers'Compensation l be d lone d the Labor Code,you moat Mnhwith comply PP rl �ryJ U p y p with such provisions or this permit shell be deemed revoked. SOUP U t ❑ - 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 totaling to building construction,and All rO bbverings 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,Indemnity and keep harmless the City of Cupenino against IiabI111les, judgments,costs and expanses which may in any way accrua against said City In consequence of the granting of thls permit. SIGN RE 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