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R 5027 (2) ERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5027 _ INSPECTION DIVISION PERMIT EXPIRATION REROOFPERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED IN WITH1B0 DAYS OF PERMIT ISSUANCE OR WI IN 1 FROM LAST CALLED INSPECTION, BUILDING ADDRESS �l, A/ Cf,1,0e�p/,, S77W F RESIDENTIAL ✓ COMMERCIAL OTHER OWNER'S /I-' AA HAZARDOUS FIRE AREA NAME CuPQK 711"o 4o GU%N C(p YES ❑ If assembly Stand that. Claw A required. �]"' NO initlal LC.B.O.W .ADDRESS ���112 el/P&S'7nnJ �J/r' EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS S vlR.�E '. CONTRACTOR` � NAME 2kaLit` //9UD-4,.,NG TO BE REMOVED TO BE RETAINED l ADDRESSl 9�/ TYPE OF ROOF COVERING CITU 8 ZIP- . EXISTING PHONE J 8� 75D oZ 3 7 BUILT-UP ROOF ❑ NUMBER ASPHALT SHINGLES LICENSE ❑ LICENSEDo CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ©' 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and effect. z� WOOD SHINGLES ' ❑ License Claes 1—yr 37 Llc.Number S�l�/'� � Date �-f- �� Contractor n OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I em exempt from the Contractor ones Law for the following reason. (Sec.7031.5,Business and Professions Cotle: Any of o county which requires a permit to construct,alter,Improve,demolish,or repair any structyy e, r r to Is Issuance,also requires the BUILT-UP ROOF ❑ applicant for such permit to file a signed ate tementthe1lb•I d pursuant to the provisions ' of the Contractor's License Law(Chapter B(commAncingyi t ectYgp 7000)of Division 3 of the Business and Professions Code)or that he la g( M th( En raf d the basis for the alleged ASPHALT SHINGLES ❑ exemption,Any violation of Section 7031.5 by sfiy no I SP MR subjects the applicant to a civil penalty of not more than five hundr 6' 011 ars 5 ❑I,as owner of the propertyor my ployeeS I as as their sole compensation,will do WOOD SHAKES ❑ the work,and the structure Is not I ad or off sale(Sec.7044,Business and Profes. sions Code:The Contractors Lic e L d apply to an owner of property who builds or WOOD SHINGLES Improves thereon,entl who doe a uc ork Il or through his own employees,provided that El such Improvements are not Int9 or oor sale.if,however,the building or Improvement Is sold within one yearol compfe(Ion, owner-builder will have the burden of proving that he die OTHER(SPECIFY) ❑✓' not build or Improve for purpose oieale.. ❑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(s)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B 6 P.C.for this reason Owner oats APPLICATION DATE VALUATION IT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: p ,x 1 ❑1 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, 4/' Ildln (,� as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this /A� permit Imo�--leeuetl. C/ Srr11C a, [Trheve and will maintain Worker's Compensation Insurance,as required by Section 3700 of L� r the Labor Code,for the performance of the work for which this permit le Issued.My Workers tJ �99 IL Companeetlon Ineurenca terrier entl Policy number are: p Tot I Carrier S'1 FuNF� Policy No. 3� �1 Z' !l4 PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.0 (This section need not be completed If the permit Is for one hundred dollars($100)or leas.) I certify that In the performance of the work for which this permit le leeuetl,I shall not am joy any person In any manner so as to become subject to the Workers'Compensation Laws of clan- All roofs shall be inspected poor any ro 'ng star al being °role' installed. If a roof is installed without first obtaining an Data Applicant inspection,I agree to remove all new materials for inspection. ecome subject OTICE TO APPLICANT:to the W°rkere Compensatlon proafter visionls ofethe 11Labor Code,cate of Exemption, mustforthwith db amply Applicant understands and will comply with all non point with such provisions or this permit shalQbe 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 coverings to be class"C"Or better. hereby authorize representatives of this city to enter upon the above-mentioned property for in. spection purposes, q (WB)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, judment9, ta end expanses which may In any way accrue against said City...consequence Ift9iegranuncosgorthjePermit. SIGNATURE OFAPPLICANT 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