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R-5462 (2) PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R— 5`p6 Z + 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 /� p 761e �Lf/tf� �QOD :_�T RESIDENTIAL COMMERCIAL OTHER OWNER'S /p A y HAZARDOUS FIRE AREA NAME J'��/ 7 ,74�t/AN YES ❑ If yeas I assembly i req that a Class A roof assembly is required. /' / N Initial I.C.B.O.k ADDRESS 7 b� f3a"r CC/?zl EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S TO r �I * T• l�INT�r �Dy�✓1 TO BE REMOVED TO BE RETAINED NAME SJ ADDRESS _ PE OFR OF COVERING CITY&ZIP AD ZAS 640 .4 /�KS)"A C,61^4711rp elf 9EXISTING PHONE 4,lDdp `0 7. BUILT-UP ROOFLICENSE ❑ NUMBER S53 3G.� ASPHALT SHINGLES ❑ LICENS d under RACTORS DECLARATION ! I hereby inion that em licensed under provisions o Chapter 9(commencing in wlih Section WOOD SHAKES ]000)of Division 3 of the Business and Professions Code,and my license Is in lull force and effect. WOOD SHINGLES ❑ LiGen9e CI939 Lic.Number S 3 Data (;n L .�7 Contractor' `�/ OTHER(SPECIFY) ❑ OWNER-BUILDS � CLARATION PROPOSED hereby affirm that am exempt Irom the Con rector's License Lew for the following reason. `�� (Sea 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 Z; applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions ` of the Contractors License Law(Chapter B(commencing with Section]000)of Division 3 at the • Business and Professions Case)or that he is exempt therefrom and the basis for the alleged ASPHALT SHING�ES exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to A e civil penalty of not more than five hundred dollars($500).): WOOD SH ES "Y I I,as owner of the property,or my employees with wages as their sole compensation,will da the work,and the structure Is not Intended or offered for sale(Sac.7044,Business and Profes. sions Code: The Contractor's License Lew does not apply to an owner of property who builds or WOOD$HI KEQ?8 improves thereon,and 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 y i � Is sold within one year of completion,the owner-builder will have the burden of proving that he am OTHER(SPIMMW,),r Elnot build or Improve for purpose of sale.). �h'r/�O ❑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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B&P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION ^ I hereby affirm under penalty of perjury one of the following declaration: / l `T ❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, /"d ^9 7 Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. Seismic 11cqjl have and willfor the pert Worker's Compensation Insurance,as required by Section 3700 of / rj p Cobarmpensation Code,for the performance of the work for which this permit is Issued.My Worker's �p©. Total Compensation Insura}nc�e carrier and Policy number are: Carrier SYg4/L �f uo Policy No.�.�,�6�`r PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.❑ ^ ^ (Tills section need not be completed it the permit Is for one hundred dollars($100)or less.) ` J I certify that In the performance of the work for which this permit is Issued,I shall nota mPloy any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shalrbe thspected prior to any roofing material being fornia. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. become subjl�lo theCE OWorrkers'Compefnsatio prolvisionis of the11cate of Labor Code,Exemption mustufo forthwith comply Applicant understands and will comply with all non point with such provisions or this permit shall be 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 covenn 0 b class o better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. spectlon purposes. n (We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, jutlgment9,costs and expenses which may in any way accrue against said City In consequence NATURE PLICANT DATE • of the granting of this permit. 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