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R 5602 (2)a OFFICE COPY NUMB R R- 5602 APPLICATION FOR CITY of CUPERTwo . 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 (AST CALLED INSPECTION. BUILDING ADDRESS RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA VES ❑ If yeaI understand thatClass A NAME_ ( GDA Q� roof assembly Is required.. NO Initial I.C.B.O.If EXISTING ROOF COVERING '1 y /� ADDRESS A¢�.4,7.{S [i l;n)n (ia PHONE QS ' NUMBER OF EXISTING COVERINGS " CONTRACTO TO BE REMOV TO BE RETAINED NAME ADDRESS/ TYPE OF ROOF COVERING ` �> CITV 8 ZIP ! O 1 XISTING / 6SO / '7109—Al PHONE ! b /q —A l I BUILT-UP ROOF ❑ LICENSE NUMBERASPHALTSHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm that I am Ilcensetl under provisions of Chapter g (commencing with Section WOOD SHAKES ❑ - 7000) of Division 3 of the Business and Professions Code, and my license Is In full force and effect. WOOD SHINGLES El License Cl a s � Lla Number Data Contractor OTHER (SPECIFY) OWNER -BUILDER DECLARA ON I hereby affirm that I em exempt from the Contractors License Law for the following re n. PROPOSED (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct,eiter,improve,demolish,air any structure, prior its Issuance, also requires the conlisant for suchpermit tofile a signedstatement that he Is licensed pursuant to the provisions rovis BUILT-UP ROOF❑ 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 ASPHALT SHINGLES 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 ($500f): C] 1, as owner of the property, or my employees with wages as their sole compensation, will do WOOD SHAKES ❑ the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes. slons Code: The Contractors Umnse law does not apply to an owner of property who builds or Improves thereon, and who does such work himself or through his own employees, provided that WOOD SHINGLES ❑ such Improvements are not intended or offered for sale. If, however, the building or Improvement la old within one year of completion, the owner -builder will have the burden of proving that he did OTHER not build or improve for purpose of sale.). (SPECIFY) ❑ ❑ I, as owner of the property, em exclusively contracting with licensed contractors t0 construct the project (Sec. 7044, Business and Professions Code: The Contractor's License Lew 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 contractors) licensed pursuant to the Contractors License Law, ❑ 1 am exempt under Sec. ,B a P. C. for this reason PROVIDE MFGR. INSTALLATION SPECS. Owner bate WORKER'S COMPENSATION DECORATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: ❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, \� as pravided for by Section 3700 of the labor Code, for the performance of the work for which this BUI ding parmll Issued. Workers Insurance, as required Section have and willfor �� ANS R ANSiD M /_ �/Y1 Y.•t/ 7� $615mIC }'L the performance f the work the Labor Code, for the pedormence 01 the work for which This permit IB Issued. My Worker's for u Worker's 's ejJll! Compensation Insurance carrier and Policy number are: �)ll Tv Ut Uut- ' t Total Carrier �j'pLQQ1` O t��L Policy Np, PERMIT AUTHORIZATION DATE CE&IPI TE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.O (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 All roofs shall be inspected prior to any roofing material being any person in any manner so as to became subject to the Workers' Compensation Laws of Cali. fornia, installed. If a roof is installed without first obtaining an Date Applicant inspection, I agree to remove all new materials forinspection. subjectmEn TO APPLICANT.It. afterofbecome Applicant understands and will comply with all non point with such provisions or this permit shall be deemed revoked. 1 source regulations. certify that l have read this application and state that the above Information to correctI agree ' to comply with all city and county ordinances and aisle Iowa relating to building construction, and All roof coverings to be Clasx" rbetter. hereby authorize representatives of this city to enter upon the above-mentioned property for in. spectionagreetos. (We) agree to save. Indemnity and keep harmless the City Cupertino against Ilebllltles, �• - /Y �_ -Fe ai of tthe granting sts and of this permit which may in any way accrue against said City In consequence I 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