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R-5586 (2) PERMIT APPLICATION FOR CITY of CUPERTINO NUMBERR_ 5586 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' Iq 8 ti0 P-66igApl RESIDENTIAL COMMERCIAL OTHER — OWNER'S HAZARDOUS FIRE AREA 7�� PI 4�-A t I_ y� YES ❑ If yeas I assembly is req that a Class A NAME AD A root assembly Is understand that 4- NO Initial I.C.B.O.If �6 • it( 94'. M5 25j 5L!xs5 6(ftk (A L4 EXISTING ROOF COVERING - ' ADDR SS �Q� p PHON os/ �p NUMBER OF EXISTING COVERINGS CONTR TOR'S NAM / (i S L TO BE REMOVED—TO BE RETAINED „ 7�, I ADDRESS r I/ TYPE OF ROOF COVERING CITY&]IP l C, SJ qSIIL EXISTING PHO Ng��1�`, —/7 "' 7� BUILT-UP ROOF CENSE NUMBER ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑ 7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and effect � ��jj//�� ((�� 77��)) I, '] WOOD SHINGLES ❑ License Clasb-,7R Number , 2.0 U Det JZ Contr —31_Qg OTHER (SPECIFY) / / act ^� OWNER-BUILDER DECLARATION PROPOSED v I hereby affirm Bu that I am exempt from Co e:Contractor'scity License Law for the following reason. (Sec.construct, it Business and Professions or rep Code: Any city or county which requires e permit to applicant alter.Improve,to file signed staairtement anystructure,prior to LLC Issuance,to theepr prs theovisions BUILT-UP ROOF applicant for such permit to file a signed statement that he Is licensed pursuant to the provlsione of tho Contractor's License Law(Chapter 9(commencing with omSectionand 7000)of Division 3 of the ❑ Q axe motion. and violation of Code)or that he Is exempt therefrom entl the bells for the alleged ASPHALT SHINGLES exemption.Any violation of Section hundred by any applicant for a permit subjects the applicant to a civil0 ,penaltys ow of not more than five hundred dollars(h wag): WOOD SHAKES P � D ❑I,as owner of the property,or to dedemployees with wages as their sole compensation,will s- the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes- sions Code:The Contractor's License Law tloes not apply to an owner of property who builds or WOOD SHINGLES SEP 1[g Improves thereon,and who does such work himself or through his own employees,provider)that �/1r� such Improvements are not Intended or offered for sale.If,however,the building or improvement I—1 �1[�(Y Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) CITY ❑ not build or Improve for purpose of sale.). (��' LUl' ❑I,as owner of the property,am exclusively contracting with licensed Contractors to construct tk l flay the project(Sec.7044,Business and Professions Code:The Contractors 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 8 P.C.Mr this reason Owner Date APPLICATION DATE VALUATION PERMIT FRE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: ❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, B as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. //Q''�� $el Ic ❑1 have and will mountain Worker's Compensation Insurance,as required by Section 3700 of 1 _ I 2r the Labor Code,for the performance of the work for which this permit is Issued.My Worker's f ' Total Comp atlon Insurance cagier an Policy n er are: Ca ,.,at N M rY -„ n� Policy No.. �/023 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 less.) / I certify that In the performance of the work for which this permit Is issued,I shall not employ any person in any manner so as to become subject to the Workers'Compeneatlon Laws of call. All roofs shall be inspected prior to any roofing material being forme. installed. If a roof is installed without first obtaining an Data Applicant inspection,I agree to remove all new materials for inspection. NOT CE TO APPLICANT: Iof Exemtio subject t.the Workers'C mpensation onwislonshot makinls of theft Labor Code,cate you n, ustufothwlltlhbecome comply Applicantunderstands ill comply with all non point with such provisions or this permit shall be deemed revoked. Source reg Ulatl On S. 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 fcoverings to b clas C"or better. hereby authorize representatives of this city to anter upon the above-mentioned property for In. spection purposes. (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, judgments,costs and expenses which may In any way accrue against said City In consequence RE 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 OFFICE COPY