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R 5179 Ilk PERMIT R_ 517 9 APPLICATION FOR CITY OF CUPEll NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 100 DAYS OF PERMIT ISSUANCE OR 100 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS ��// 1� /� � 5J/f�O �ICl 4VVO�) Com( - RESIDENTIAL COMMERCIAL OTHER -_ OWNER'SyA HAZARDOUS FIRE AREA JN (.!-/A VES El If yes-I understand that a Class A NAME �� %% roof assembly is required. /O D /�/� NO Initial I.C.B.O.g t ADDRESS_/ ` �a l ^' ."�/ ��/, EXISTING ROOF COVERING $ PHONE �-y- NUMBER OF EXISTING COVERINGS C CONTRACTOR'S m s Y�a NS TO BE REMOVED TO BE RETAINED NAME ADDRESS el D /-`- -ill(j S?T sP_ eJ TYPE OF ROOF COVERING CITY&ZIP '7 ��' c{O f J L7/ Q�lU e ISTIBUILT-T- PHONE UP ROOF `LICENSE ❑ NUMBER 59O/ 'o°S� ASPHALT SHINGLES \ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and anent. 2 WOOD SHINGLES ❑ License Claes G3 Lie.Number 50✓ Date L Contracmr Qd I! OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION VPROPOSED I hereby affirm that I am exempt from the Contractor's License 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 ❑ El of the Contractors License Law(Chapter B(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 ASPHALTSHINGLES exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to e civil penalty of not more than five hundred dollars($500),): WOOD SHAKES ❑I,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 eels(Sec.7044,Business and Profes. alone Code:The Contractors 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 axle.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,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 ill licensed pursuant to the Contractor's License Law. PROVIDE MFG R. INSTALLATION SPECS. I em 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: g�� ❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, C Buildin as provided for by Section 3700 of the Labor Code.for the performance of the work for which this permit Is Issued. rG O 0?rTa-ve and will maintain Worker's Compensation Insurance,as required by Section 3700 ofSeismic tlggshe Labor Cotle,far the performance of the work for which this permit Is issued.My worker's t_ O Compensatlo I ur a cerrlerend Policy number are: t't.. , Total carder �� �� Policy No. 4/�S PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.I] '( (This section need not be completed It the permit Is for one hundred dollars($100)or leas.) I 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'Compeneallon Laws of Cali. All roofs shall be inspected prior to any roofing ater I being fornia, installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. NOTY ecome subjecctlCE TO APPLIANT:to the Workeres'Compelnseteon prolvisionis of the iLabor Code,cate of you mustfo forthwith ushould bcomply Applicant understands and will comply with all non point with such provisions or this permit shalpbe 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 coveMgsto be cls 'C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In- spection n- Spe(We) purposes. /�..JG/ le (We)agree to save,Indemnity and keep harmless wa the City ai Cupertino Ci against liabilities, ence • judgments,coats and permit. s which may in any way accrue against aeltl City in consequence of ma 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