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R 5871 (2) J PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5871 REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (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 CUP Z7-IAJO I �� `) .LJe v'CRZOA3 `_,)fz ' 1Y,"if 0 RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA �-D M IIID AI)c EV M T YES ❑ If yes—I understand that a Class A . NAME r1 (,2, /�' HEAJT_ assembly is required. C NO Inigal I.C.B.O.N ADDRESS 'Z SS N• N,+P Fc eT ST+ J;T EXISTING ROOF COVERING PHONE 2_7:M Tb NUMBER OF EXISTING COVERINGS CONTRACTOR'S NAME ne-W A l 5s AejC2 ROO F I NLs �O _ TO BE REMOVED .45it TO BE RETAINED ADDRESS Zz.q L LtNcoL+o y4Ve. S$ QS12S TYPE OF ROOF COVERING CITY B ZIP otL EXISTING wV PHONE (40%) 'tog 1} BUILT-UP ROOF CAP LICENSE 5Sa�"36 NUMBER ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES P � D 7000)of Division 3 of the Business and Professions Code,and my license Is n full force and effect. r cp / WOOD SHINGLES �W License Class Lic.Number 5;27��6 APR 2] AMID Date�,/T9� Contractor -if&p"1_JSaMce RAC, OTHER(SPECIFY) LFJ, A11S71Y OWNER-theConRDECLLicensN PROPOSED C(TMUfGUf'triflNU hereby affirm Ines am exempt from the e: Any city License Lew for the lino a reason, (Sac.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 13 4:20-- 2,11"1I{/,n applicant for such permit to file a signed statement that he is licensed pursuant to the provisions MI W EL..4 L VfT of the Contractors License Law(Chapter g(commencing with Section 7000)of Division 3 of the ff Buenas.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 a civil penalty of not more than five hundred dollars($500).): [3 1.as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES El 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.II,however,the building or Improvement Is sold withln 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 eels.). ❑1,as owner of the property,em exclusively contracting with licensed contractors to construct kc— 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 bulids or Improves thereon,and who contracts for such projects with a contractor(.)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B 6 P.C.for this reason OwnerDate WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: ❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, 1l Building asprovidedis Is for by Section 3700 of the Labor Code,for the performance of the work for which this t11Q( • g permit idedfed. 1r/ yl\P E I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic -the Leber Code,for the performance of the work for which this permit Is Issued.My Workers Compensation Insurance carrier and Policy number are: Total Carrier 15;_47e FUND Policy No. ,B.ZAlD y2S�, 3 PERMIT 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.) 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 rnntS Shall be fhRpected prior to any roofin material being lornia. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become subject to the Workere'Com enation provisions of the Labor Code, Applicant understands and will comply with all non point I P D you moat forthwith comply PP p y with such provisions or this permit shelCba deemed revoked. SOUfCe 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 ortlinances and state laws relating to building construction.and AI o Icoverings to be 'o better. hereby authorize representatives of this city to enter upon the abovo-mentionod property for In- spection purposes. (We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilebllitles, judgments,costs and expenses which may In any way accrue against said City...consequence All of the granting of this permit. SI NATURE OF APPLICANT ATE 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 .