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R 5876 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R_ -5876 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 p A,/7 C/7 - /D 1I / 6fK1 4A, 77 RESIDENTIAL COMMERCIAL OTHER OWNERS HAZARDOUS FIRE AREA AW46 YES El 11 yas—I understand that a Class A NAME [/ roof assembly is required. NO ❑ Initial I.C.B.O.k ADDRESS �y Z-57 EXISTING ROOF COVERING 257 Z4 PHONE O 7 Z NUMBER OF EXISTING COVERINGS I CONTRACTOR'S Q UDTO BE REMOVED , NAME_ SLS © / /t UO����r TO BE RETAINED ADDRESSp y /� TYPE OF ROOF COVERING CITY&zip ���[[Si A( kii L.� &4 , CIF / . PHONE YDS '— ! Z7 --Ov� b�j ell EXISTING BUILT- iBUILT-UP ROOF '❑ LICENSE / /� NUMBER (� T 7-0 / ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I ani licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and.Profasslons Code,and my license Is in full force and - effect. R 4 7 WOOD SHINGLES' El License Class'S/� /p L� Lie.Number kms/ • ` 7- Date T�� 9C5 Contractor /bfr//h 6 Ve_7Ke 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 Pmfesslons Cotle: 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 pp of the Contradoes License Law(Chapter 9(commencing with Section 7000)of Division 3 of the p F� Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to W` a civil penalty of not more than five hundred dollars($500).): ❑1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKEy�{, N the work,and the structure Is not intended or offered for sale(Sac.7044,Business and Profea- \se•'� ttOv slons Code:The Connector's License Law does not apply to an owner of property who builds or Improves thereon,and whe does such work himself or through his own employees,provided that WOOD SHINGLES & uV[T�t F1such improvements are not Intended or offered for sale.16 however,the building or Improvement Cit v 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.). [:11,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. 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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 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 undo,penalty of perjury one of the following declaration: ❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building/If as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this ^ / a..Or �.T tI�armlt'e Issued. ^ coy ( fJV KJ '^ have and will maintain Worker's Compensation Insurance,as required by Section 3700 of r / ! Seismic L or Coca,for the performance of the work for which this permit Is}'_sued f.�y Workers Total O Compensation Insurance carrier and Policy number are: ZZf.- (�8 Carrier 'e7/ x F=G)Njh, Policy No. 6614PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.CQ (This section need not be completed If the permit IS for one hundred dollars($100)or less.) Q O 7 UX I canny 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. NOT CE TO APPLICANT. It,after of Exem subject to the Workers'Compensation provisionmakinls o Certificate Labor Code,yolu mustuforthwliitthbecome comply Applicant understands and will comply with all non point with Such previsions or this permit shall be deemed revoked. source ulations. 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 buildingconstruction,and All Ofc veringst a "C" tter. hereby authorize representatives of this city to anter upon the above-mentionatl property for In. spection purposes. (We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, judgments,costa and expenses which may in any way accrue against said CIN In consequence • 9t the granting of this permit, . SIGNATURE 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY