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R-5306 (2) PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 5306 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 IAST CALLED INSPECTION. BUILDING ADDRESS / 10 01 Scvvt9_q— e- (Z-71- 'RESIDENTIAL `/ COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA AQ ^ YES E] If yes—I understand that a Class A NAME rn r 4 W rS N 5�t V root assembly is required. NO Initial I.C.B.O.p ADDRESS 10401 EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERIN S CONTRACTOR'S n - NAME Fn!6- C.)Aj+i TO BE REMOVED TO BE RETAINED ADDRESSP �nX &S_S TYPE OF ROOF COVERING CITY&ZIP qsp� EXISTING PHONE --)7-)- 039J BUILT-UP ROOF ❑ LICENSE NUMBER (0 :,-'l 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 full force and enact. 9 WOOD SHINGLES License Class Up.Number 92g ❑ B'S'G� OTHER(SPECIFY) �/ Data Ccntrecto OWNER-BU E- IARATION PROPOSED l•� I hereby affirm that I em exempt from the o ttractor's License Law for the following reason. J 9 (Sec.7031.5.Business and Professions Cada: 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 applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Lew(Chapter 9(commencing with Section 7000)of Dlvislon 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 a civil penalty of not more than five hundred dollars($500).): ❑I.as owner of the propertyWOOD SHAKE$,or my employees with wages as their sole compensation,will do ❑ n the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes- sions Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES QFj.0 improves thereon,and who does such work himself or through his own employees,prvided that ❑ t S such Improvements are not Intended or offered for sale.ll,however,the building or improvementF1`e,-7 Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) 7"r/ SLt%N(i�s not build or Improve for purpose of sale.). ❑I,as owner of the property,em exclusively contract ng with licensed contractors to construct the project(Sec.7044,Business and Pro eseo (Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of property who but de rim lovas thereon,and who contracts for such projects with a contractor($)licensed pursue 1 th onira ars License Lew. PROVIDE MFGR.INSTALLATION SPECS. ❑I em exempt untler Sec. ,B 8 P.C.for this reason ©• 5- 3• S Owner Date WORKER'S COMPENSATION DECLARATION '+'APP ICATIO r� E VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: � 1 ❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation- n BW(ding asprovidetll by Section 3700 o1 the Labor Code,for the performance of the work for which this dry Va f/ �j.� permit Is l etl. q(' Seismic ao ve end will maintain Worker's Compensation Insurance,as required by Section 3700 of (�(/ the'&Code,for the performance of the work for which this permit Is Issued.My Worker's rcti �2?d Total Componsellon Insurance carrier and Policy number ere: //tr - ST IF_ FVWD woo.2_,65-C17,, Carrier Policy W r`+�-�+I Z to PERMIT AUTHORIZATION DATE CERTIFICATE EN ATION INSURANCE FROM WORKERS' COMPENSATION INSURANCE N.C.[ (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 Compensation Laws of Call- All roofs shall be inspected prior to any roofing material being fornla. - installed. If a roof is installed without first obtaining an Date Applicant 4 inspection re to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making this rilcafe of Exemption,you should become (k ll nt unde lands and will comply with all non point subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y with such provisions or this permit shell be deemed revoked. so ce regul Ons. - I certify that l 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 I roof CO rI c ss"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In- spection purposes. fill / (We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, judgments,costs and expenses which may in any way accrue,against said City In consequence of the granting of this permit. SI UFIF ICTFAPIPEIENT DATE fee PRE-INSPECTION: PLYWOOD: IN-PR INSP. DATE INSP. DATE INSP, DATE - TEAR OFF INSPECTION: BATTENS: FINAL: INSP. DATE INSP. DATE INSP. DATE bz». NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION __ _ OFFICE COPY