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R-5628 (2) PERMIT R_ 5628 APPLICATION FOR CITY OF CUPERTINO NUMBER 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 7j1 /•�' RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA y i /G,� YES ❑ If yes-I understand that a Class A NAME �✓/�-'�-C roof assembly is required. ' rx �� � � ���� NO 1-11Initial I.C.B.O.M ADDRESS_ 8/?}', 'j� S EXISTING ROOF COVERING S PHONE Yo U /� ✓ — �J NUMBER OF EXISTING COVERINGS CONTRACT.OFrS TO BE REMOVED / TO BE RETAINED NAME ADDRESS Pi_�7/1) �lN11 TYPE OF ROOF COVERING CITY a ZIP EXISTING z7� PHONE i! BUILT-UP ROOF El LICENSE �01 p S NUMBER ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am Ilconsed under provisions of Chapter 9(commencing with Section HAKES 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and effect. G GLES ❑ License Class �/ 3� LIc.Number �` Date 5!/ 112 7 Contractor G 4l' OT �.(s�PECIFY) ❑ OW .1 DER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractors License Lew for the following reason. ' (Sec.7031.5,Business and Professions Code: Any city or county which requires a permlt to construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also require.the BUILT-UP ROOF Elapplicant for such permit to file a signed statement that he Is licensed pursuant to the provlslons • of the Contractor's License Lew(Chapter 9(commencing with Section 7000)of Division 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 P A I D a civil penalty of not more than live hundred dollars($500).): ❑ 01,as owner of the property,or my employees with wages as their able compensation,will do WOOD SHAKES the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profen 7 I[Cbpp pp��p� slons Code: The Contractor's License Lew does not apply to an owner of property who builds or Improves thereon,and who does such work himself or through his own employees,provided that �AYC3 WOOD SHINGLES such Improvements are not Intended or offered for sale.If,however,the building or Improvement Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) CITY UF,e�+ not build or improve for purpose of sale.). CITTIIy� ❑I,as owner of the property,em exclusively contracting with Ilcensed 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 no builds or Improves thereon,and who contracts for such projects with a contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B 8 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: ❑1 have and will maintain 37 a o Certificate Lab of Consent to sell-Insure for Worker's Compensation, ^_(�^ �O� Building ee mit Is tl rby Section 3700 of the Labor Code,for the performance of the work for which this ` 7 / permlt Is ad. Seismic eve and will maintain Worker's Compensation work which this as required Is by Section 3700'of s the bor Cotle,for the performance of the work for which this permit Is Issuetl.My Worker'6 Compensation In renca carrier antl Policy number ere: p Total Carrier ��r«�� Policy No. e16'6 Y(�d PERMIT AUTHORIZATION DATE CERTI KATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.O -9—k (This section need not be completed If the permit Is for one hundred dollars($100)or less.) s ` / I Certify that in the performance of the work for which this permit Is Issued,I shall not employ any person in any manner so as to become subject to the Workare'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being fornia. installed. If a roof is installed without first obtaining an Dale Applicant inspection,I agree to remove all new materials for inspection. subjlect toEtheOWorrkers'C mpens tlon prowsione ofethefl Laborr Code,yolu must bRhwlltlhbcomply Applicant understands and will comply with all non point with such provisions or this permit shell be deemed revoked, source regulations. I certify that I have read this eppllcatlon and state that the above Information is correct.I agree to comply with all city and county ordinances and state laws relating to budding construction,and All r of cov 1gs to be la C"or better. hereby authorize representatives of this city to enter upon the above mentioned property for Im 9 ///.�$'� aPo Wet purposes. C! a2/^L!C/i `� (Wet agree to save,Indemnity and keep harmless the Clry of Cupertino against Ilablllllos, pl fudgeants,grantcosts andhis expenses e mies which may in any way accrue ogtnst said City In consequence 'SIGNATURE OF APPLICANT DATE ' 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