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R 5779 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5779 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 160 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. • BUILDING ADDRESS - 79 Z / /��(����//�j/✓ g� RESIDENTIAL COMMERCIAL OTHER OWNER's /! HAZARDOUS FIRE AREA G� � Aa MNlli YES ❑ It yes—I understand that a Class A NAME / /�� roof assembly is required. NO Initial I.C.B.O.# ADDRESs h7 - EXISTING ROOF COVERING PHONE `ii(6?r 75-7— S/ NUMBER OF EXISTING COVERINGS CONTRACTORS NAME / eQMi �i. p� �. TO BE REMOVED TO BE RETAINED r`W ADDRESS' TYPE OF ROOF COVERING CITY&ZIP_/6 'r0 $. % S S.S EXISTING PHONE . PHONE `� Z BUILT-UP ROOF LICENSE ❑ NUMBER'17,'l-7 7 Z ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES ❑ 7000)of DIvlalon 3 of the Business and Professions Code,and my license Is In full force and effect. `? WOOD SHINGLES ❑ License Class `I� Lie.Number ����7�- Data S Z L-9P' Contractor GI �/A+i,1�-o iv9 OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED 1 hereby affirm that I am exempt from the Contractors License Law for the following reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to ,q construct,after.Improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF4 'lI' applicant for such permit to fila a signed statement that he is licensed pursuant to the provisions ANY . of the Contractors License Law(Chapter a(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he Is exempt therefrom and the basis for,the alleged ASPHALT SQ13LE 1.00 ❑ exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant toper. a civil penalty of not more than five hundred dollars($500).): OF ❑1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES `GN` the work,and the structure is not Intended or offered lot sale(Sec.7044,Business and Proles- ♦' cions Code:The Contractors License Law dos not apply to an owner of property who builds or •l//,At,, Improves thereon,and who does such work himself or through his own employees,provided that WOOD SHINGLES HYo ❑ such Improvements ere not intended or offered for sale,If,however,the building or Improvement Is sold within one year of completion,the owner-builder will have the burden of 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(See.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 confractons)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION $PFOB. ❑I am exempt under Sec. ,B 8 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: y...s1 ❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building`l—L/J'— as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ww Seismic ❑ have and will the performance Worker's Compensation thekfor Insurance,as squired by Section 3700 of �L�taS „the Labor tiotl insurance the performance of the work for which this permit Is leeuatl.My Worker's Compeneedtmn-Insurenco carder and Policy nu�r ere: tl / Total Carriedzn�r�Q/t/ AIV. �Policy N g'BH 07 3/3V PERMIT AUTHORIZATION DATE CERTIFICA7EOFEXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.0 • �^ �I (This sadden need not be completed If to 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 Cali- All roofs 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. subject toE a WorkersTO 'Compennsation provisions of theflcate of Laborr Code,Exemption, must forthwithcecome omplyApplicant understands and will comply with all non point with such provisions or this permit shal0be deemed revoked. Source regulations. 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 relating to building construction,and All roof coverin to ass"C"or better. -hereby authorize representatives of this city to enter upon the above-menllonod property for In. f G O spection purposes. ZZ- (we)agree to save,Indemnity and keep harmless the City of Cupertino aggalnst liabilities, (r judgments,costs and expenses which may In any way accrue against said City In consequence of the granting of this permit. IGNATU F 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