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R-5512 (2) ERMIT APPLICATION FOR CITY OF CUPERTINO NU BER R- 5 512 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 M L) RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA YES ❑ It yes-I understand that a Class A {/��A •� NAME l IS31I&Irlt _ . �nZ>I=tl;z•1 't— tox-riz tl^.Iq roof assembly is required. — iT- NO V Initial I.C.B.0.8 ADDRESS IOSa-� CSG7�]\R� >_At�- EXISTING ROOF COVERING PHONE 6 _ S 4S9 NUMBER OF EXISTING COVERINGS , CONTRACTOR'S TO BE REMOVED 1 TO BE RETAINED NAME_ � .�\. GfJ TFSZIPSL Imo..=•G L _�9PL77.71a \T ADDRESS (� TYPE OF ROOF COVERING CITYSZIP 5l }iC ►4E<F3� AM9Ati�C>11F= oSa EXISTING PHONE�4C)�7 -�-5'-g 4,0 BUILT-UP ROOF ❑ LICENSE NUMBER 36-7sso ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION / I hereby affirm that 1 em Ilconsed under provisions of Chapter a(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and effect. ��ii WOOD SHINGLES ❑ License Class Llc.Number 3 y7 S T Data -1 `qT `1 Contractor&M. nU zv. OTHER(SPECIFY) ❑ OWNER-BUILDERde: Any city or TION PROPOSED - 's I hereby affirm that I em exempt from the Contractor's License Law for the following reason. (Sec.7031.8,alter.improve. and Professions or rep Code: Any city Or county which Issuance, also requires e permit to constapplicant signeepaaeny menthatstructure,prior toIts 1pursuantalsoreprovesthe BUILT-UP ROOF ❑ applicant for such parent a file a signed statement that he Is licensed pursuant to lila provisionsofthe of the Contractor's License Law )or that a(commencing with Section 7000)of for the 3 of the • Business and Professions Soda)or that he Is exempt therefrom and the bests for the alleged ASPHALT SHINGLES ❑ exemption.Any f-o t more of Section hundred by any s($ 0 applicant for a permit subjects the applicant to e civil penalty of not mora then live hundred dollars(5500).): WOOD SHAKES ��' /////� ❑I,as and er the f thestructure I not I my tendedemployees ed wages as(Sec.their sole compensation,BusinesandPr111 s. ,/ C.{' the work,entl h e strucWre is not intended ores not apply fury to (Sea owner of property and Prolan 1. dons Code:The,anwho des such Law tlimnotapplytoenowner ofployees,who builds or WOOD SHINGLES / Improves thereon,entl who does such work himself or through his own employees,Improvement ant such d within oneyeare not platin,tended oro fferedforsale.It,111 however,thebuildingpros Improvement L+ not build or prove for purpose of Owner-bulltlerwlll have the burden of proving that he tlltl OTHER(SPECIFY) 40 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 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 A with a contlicensed pursuant to the Contractor's License Lew. gOVIDQ YFGR. INSTALLATION SPECS. ❑ exempt em exemptt under See. ,B 8 P.C.her this reason V Owner Date LI DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: ❑t have and will maintain a Certificate of Consent to self-insure for Workers Compensation, LLr Building I 7 O as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 040permit Is Issued. V- IS:0 0• - ❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of Seismic the Labor Code,for the performance of the work for which this permit Is Issued.My Workers Total 2 •g Compensation Insurance carrier and Policy number ere: Carrier Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.[] © � ^ T, O �-( /`q 7 (This section need not be completed If the permit Is for one hundred dollars($700)or less.) J 1 certify that in the performance of the work for which this permit Is Issued I shell not employ any person In any manner so as to become subject to the Workers'Compensation Laws of a11. All roofs shall be inspected prior to any roofing material being hernia' installed. If a roof is installed without first obtaining an Date 7)a �9 , Applicant e inspection,I agree to remove all new materials for inspection. NOT ICETO APPLICANT: If,alter making this Certificate o xemption,you should become Applicant understands and will comply with all non Sint subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply P y P 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 OrdInences 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. AAA ep(We) purposes. ^- � � 7A /�� (We)agree to save,Indemnify and keep harmless the City of Cupertino against Ileblllllos, /`old pz� / , -/ judgments,coats and expenses which may In any way accrue against said City In consequence • of the granting of this permit. SIGNATURE FAPPLICANT -��AT� 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 ® 10300 Torre Avenue • (.;iLv of Cupertino. CA 95014 - �upert.1110 Buildin Division (408)777-3228 (408) 777-3333 (fax) f March 20. 1993 Homeowner 10523 Esquire Place Cupertino, CA 95014 SUBJECT: REROOF PERMIT Dear Homeowner: We have been going through our files in the Building Department, and contacting those people with re-roof permits remaining "open". Our records show that either you or your roofing company have not: (1) called to schedule a final inspection, or(2) missed getting • the sign-off after calling us for a final. Sometimes an inspector will return to a job and sign off the permit in the field, but neglect to inform staff for input into the computer. If this is the situation and your permit card shows the final sign-off, would you please contact us so we may complete our computer records? If the permit is not signed off, please call to schedule an inspection for final closure of the permit. Because of the large volume of paperwork within the building department, we cannot separately monitor the progress of each permit. We ask that you give this notification your immediate attention. If we do not hear from you within fifteen (15) working days, we will expire the permit and remove the records from our computer. Thank you for your assistance. Sincerely. CITY OF CUPERTINO Christv Akatiff. Administrative Clerk Prmrod on Pecmleo Piper