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R-5374 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5374 . 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 Ill 2D #_ mw.n l I RESIDENTIl COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA NAMESi Amr�k SAn VES ❑ roof assembly isrequired. Class root assembly isand that q NO ❑ Initial I.C.B.O.It ADDRESS 3 1 9 5 �eC i t LV) EXISTING ROOF COVERING PHON O y31- °1388 NUMBER OF EXISTING COVERINGS I CONTRACTOR'S yn/M NAME .JCai a(gop.o. TO BE REMOVED `t TO BE RETAINED ADDRESS / ...�� /\fits ./1_. I C S p�I TYPE OF ROOF COVERING CITV 8 Z(,IP l0�^-�` ^� ��t1 W J / EXISTING PHONE&O!� / 1 -n 11� BUILT-UP ROOF El LICENSE OZ L v ASPHALT SHINGLES ❑ NUMBER LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license lain full force and effect. 13 �` WOOD SHINGLES El License Clas _q 1 C ZD Lic.Number yy� Dets�d_I&' r contractor 5 OTHER (SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I 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 ❑ /� 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 of the Contractor's License Law(Chapter 9(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 SHINGLES • exemK ption.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).): 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 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 El thereon,end 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) E]not 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 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 comractor(e)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑I am exempt under Sec. ,B 8 P.C.for this reason Owner Data WORKER'S COMPENSATION DECLARATION APPL•IC TION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: '+ / F7 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, C' BUllc!14 as provided for by Section 3700 of the Labor Code,for the performance of the work for which this rillpermit Is issued. rI �/r Seismic ❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 0l n the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's��r Compensation Insurance carrier and Policy ii are: �{ (Jf Total Carne&fllbI I'L � Pp;;py No,357-1 ib ) PER 7-AUTHORIZATION DATE CERTIFICATE OF EXEMPTI N FROM WORKERS' s/r COMPENSATION INSURANCE RANCE N.O❑ (This section need not be completed if the permit is far ono hund do a($100)or lass.) I certify that In the performance of the work for which this parml Is issu ,I shall no employ any person in any manner so as to become ct to the Workers' nsatipn Law pi call- All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an Datep, G� Applica inspection,I agree to remove all new materials for inspection. subject CE TO ow rrkersCOom ensiion proivisionis Certificate of s of the Labor Code,yolu must forthwith le Applicant understands and will comply with all non point P P Y PY with such provisions or this permit shell be deemed revoked. fCe regulation5AP 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 of covering lass"C"or better. hereby authorize representatives of this city to anter upon the above-mentioned property for In- spection purposes, (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, �IIJI J judgments,costa and expenses which may In any way accrue against said Olt y In consequence of the granting of this permit. SIGNATURE OFANT 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