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R-5379 (2) PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R— 53 7 9 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 GALLc�a�e RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA t 1 YES ❑ If yes—I understand that a Class A NAME �. V roof assembly is required. r/ / NO Initial I.C.B.O.If ADDRESS-�/O_6 y��_1Z1J h1,0AI'e DID EXISTING ROOF COVERING PHONE — © NUMBER OF EXISTING COVERINGS CONTRACTOR' we i1. SO,�f. TO BE REMOVED TO BE RETAINED NAME hV L rT6�C ADDRESS 1/ /�// a_�Y „ /a �C�� Q spa TYPE OF ROOF COVERING CITY a ZIP //7T/ (X/'� Kldl it EXISTING PHONE `vCg t/ 74' C.S BUILT-UP ROOF ❑ LICENSE Q ASPHALTSHINGLES ❑ NUMBER L� LICENSED CONTRACTORS DECLARATION I hereby affirm that I em 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. WOOD SHINGLES License Cleas� Lic.Number 4,5-OL,5-& �(f•fit f.9'7 n OTHER(SPECIFY) Date Contractor OWNER-BUILDER EC's License PROPOSED hereby affirm Bu that am exempt from the Contractor's License Law for the following reason. / ) (Sec.7031.8,Business and demolish, or rep Code: Any city or county which requires a permit to QCr,_TflLC/ construct,alter,Improve,to file a signed stair any tement that prior lose Issuance,pursuant alsto he provisions of BUILT-UP ROOF of the Contractor's for each permit a lila a signed statement that he is licensed pursuant Ip the provisions ' of the Contractor's License Lew(Chapter a(commencingIsexempt xptwith Section 70001 of Division 3 of the G Business and violation of Code)inlet he Is any pt antfora and the beats far the alleged ASPHALT SHINGLES / exemption.Any violation of Section hundred by any applicant for a permit subjects the applicant to e civil,penaltys ow of not more than floe hundred dollen(h wag): WOOD SHAKES ❑ ❑I,as owner of the property,or to employees with wages as their sole compensation,will Profes- sions work,and the ontracre is not Intended or veered for sale(Sea owner of Business entl builds es the The Contractor's es such Lew 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,Iprovidedrthat each Improvements are not intended or offered for seer. ill however,the building or Improvement Is sold not or prove for purpose sthe ownerbuilderwillhave the burden obprovingthat he did OTHER (SPECIFY) ❑ not Oulltl or improve for purpose of sale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors 10 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 WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE 1 hereby affirm under penalty of perjury one of the following declaration: P A I D ❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit)yy'�rss°ed. 14 Seismic L V.1"e end will maintain Worker's Compensation Insurance,as required by Section 3700 of OCTy R[pr .the Labor Coda,for the performance of the work for which this permit is issued.My Worker's �L6 O^ Total Compensation lnsur w carrle�and Polio mbar aro: ,j) n (i4► Carrier�1/�'�-e �N f>oh,yN -)�`�j -lU Pr WAn.HORIZATION DATE CERTIFICATE OF EXEM WORKE - COMPEN INSURAN E N. y� /y•� 'Q �� �n (Thos section need not be comp) if the perms Is for o e h ad Is r lass.) I certify flat In the perform of Iha work far which th' p t u s n employ any person In any manner a to become subject to th k S. a n e of cafe- All roofs shall be inspected prior to any roofing material being fornia. Ili -7 installed. Dof is installed without first obtaining an Daro�� Applice ins on,I agr to r v materials for inspection. NOTICE TO LICANT: If,alter ma g r ficate 'E mpt n,you should become licant unde s nd nd m I with all non oint subject to the rkere'Compensation provislone of the Labor Co e,you must forthwith comply PP P Y P with such pro r Ions or this permit shal0be deemed revoked. Source regula S. I certify that I have road this application and state that the above Information Is cXhabinities, to comply with all city and county ordinances and state laws relating to building connalAll roof cov g =aF-better - hereby authorize representatives of this city to enter upon the above-mentioned p spection purposes, / _ (We)agree to save,indemnity and keep harmless the City of Cupertino agat judgments,coats and expenses which mayIn any way accrue against said Clry' consequence S UR OF APPLICANT •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 r-I OFFICE COPY I