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R 5319 APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5 319 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR • IN DAYS FROM LAST CALLED INSPECTION, BUILDING ADDRESS / / J/ SIDENTIAL COMMERCIAL OTHER W HAZARDOUS FIRE AREA NAME YES ❑ II yes—I untleatand that a Class A roof assembly is required. NO L Initial LC.B.O.M ADDRESS "� EXISTING ROOF COVERING •T PHONE NUMBER OF EXISTING COVERINGS CONTRA R'S NAME TO BE REMOVED TO BE RETAINED AD 'S 61 TYPE OF ROOF COVERING CITY 8 zIP7S.C�'L� . /�IdS 5t S.s dose �� �js/aG EXISTING PHONE BUILT-UP ROOF ❑ ,:� NIUMBER / ASPHALT SHINGLES 4l Co-*4, LIC SED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑ /@ Gr^^//� 7000)of Divlalon 3 of the Business and Professions Coda,and my license Is In full force and V yCTI Lieffen 7C WOOD SHINGLES ❑ �/g License Clesa It.Number 9) OTHER(SPECIFY) ❑ Data �- contractor 0 NER-BUILDERR N PROPOSED I hereby affirm that I am exempt from the Donato or'&LIc°nea Lew for the following reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to en y construct,alter,improve,demolish,or repairanystructure,prior to Its Issuance,also requires the BUILT-UP ROOF Npp� d R�t applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions • of the Contractor's License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Cade)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINgtcal,�r��,,'" /- exemptlon.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to (xUrtry V a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES E)1.as owner of the property,or my employees with wages as their sole compensation,will do ❑ the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes- sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES Improves thereon,and who does such work himself or through his own employees,provided that ❑ such Improvements are not Intended or offered for sale.if,however,the building or Improvement Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) El build or Improve for purpose of sale.). ❑I,as owner of the property,em exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of property who builds or Improves thereon,and who contracts for such projects with a contractor(&)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 em exempt under Sac. ,S$P.C.for this reason Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT F I hereby affirm under penalty of perjury one of the following declaration: ❑1 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, r Build! O as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this /^/ C permit Is Issued. ` C✓ �+Q^ ❑Ihaveantl will maintain Worker' o pensation l,ksurance, req d S von3700o1 I7 �,,L./. Seismic _the Labor Code,for the erformano f work for wh I tl.M Worker's / Compensetl n Ina entree artier an o n gapi� y Total Carrier Y//J,yr'. Policy No. PERMIT AUTHORIZATION DATE CE TIFICATE EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C. (This section need not be completed If the permit Is for ono noted dollars($100)or less.) O U I certify that In the performance of the work to hlch 1hl p r It Is Issued,I shall not any person In any manner so as to become sub to the or a'C mpensatlon Lew °`nia, roofR shall be inspected prior to any roofing material being stalled. If a roof is installed without first obtaining an Date 7 Applicant A spection.I agree to remove all new materials for inspection. subject to the wm er$'Compensation fter provisi nis lir Labor Code,yoiu mustuforthwhouith compro. Applicant understands and will comply with all non point with such provisions or this permit shalPbe deemed revoked. SO regulations. 1 certify that I have read this application and state(hat the above Information is correct.I agree ^^�� to comply with all city and county ordinances and state law.raising to building construction,and Iroo Coverings to Is 5„G"Or better. hereby authorize representatives of this city to enter upon the above-mentioned property for in. spection purposes. L (We)agree to as,.,indemnity and keep harmless the Clty of Cupertino against liabilities, ' of the which may in any way accrue against as e g anting of this permit. id CIN In wnsequence SIGNATURE OF/ ICANT 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 n FFlr`F MPV