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R-5454 PERMIT APPLICATION FOR CITY of CUPERTINO NUMBERR_ 5454 . INSPECTION DIVISION PERMfT EXPIRATIO REROOF PERMIT (406)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED - WITHIN 180 DAYS OF PERMIT ISSUANCE OR • 100 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS io o g 9 S f\Q • RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA ��X 1 YES ❑ N yes—I understand that a Class A NAME _ roof assembly is required: /I NO ❑ Initial I.C.B.O.# ADDRESS 3sG c��—`�p�`^�e `�' `�"'�`'�t{ �IXu--t'oACdhl� EXISTING ROOF COVERING PHONE 6 b'O— J L 6_3 aO NUMBER OF D(ISTING COVERINGS / CONTRACTOR'S �J /� TO BE REMOVED�TO BE RETAINED NAME�YJy_� 'F-r®O YL-Q� CW •ADDR - , TYPE OF ROOF COVERING CITY a/(/z a t$?S-.3 S-T ? � ��- 3,T, G4,?5 FISTING PHONE�) BUILT-UP ROOF ❑ LICENSE S NUMBER o— ASPHALT SHINGLES El LICENSED CONTRACTORS DECLARATION ' I hereby M r.that I am licensed under provblon°of Chapter a(commencing wM Section WOOD SHAKES - 7000)of Dlvlelon 3 of the Bualnam and Professions Code,and my license Is In full force and w affect 3 a b WOOD SHINGLES m Ucee Cleve Lk.Number Data �3l-� Contra or' OTHER(SPECIFY) .Q OWTJER the Cont DEC oN PROPOSED ' hereby affirm that Pam exempt Profes from the Code: Any cry LIcanSa Lew for the uirestolImIng remon. cont.7031.5,r,Impr m end Prole or repair e ir" Any dry or county which requires e - comlruct,atter,Improve,to Its a signed pt tem tthatStructure,prior to ma leeuerne,a Nums lh �.11LT OOF ❑. applicant M each permit to file a egnm statement that he le Ilcemed pureuent t roviso of the Contractors Lkenm Law(Chapter B(commend pwith Section 7000)of 3 of ® Buslnem and Prolemlons Code)or Chet he le exemptaI arefrom and the burls t alleged ASPH SHINGLES exemption.Any violation of Section 7031.8 by any applicant for a permit subjects IkantI a cMI penalty of not more than five hundred dollars(55001.): �Iq1 (x7�.r7�(o� ]I,as owner of the property,or my employees with vrepeem their sole compo tion,Mlr06G to KES'. ❑ the work,and the Structure Is not Intended or oHered for Sale(Sec.70",Busn Press. sons Code:The Contractors LJcenm Lew does not appy to an owner of property builds or WOODS NGLES Impws me thereon,and who doss such work himself or through his awn employms, km that ❑ such Improwmanta are not Intended or offered for oak.If,however,the building or rrp ment Is Sold within one year of completion,the owner-builder will have the burden of provi M (SPECIFY) ❑ not build or improve for purpose of Sale.). ❑I,as Owner of the property,am exclusively commoling with licensed contractors to construct the prolM «.(S7oea,Busnma and Professore Coda:The Contractors License Taw does not •PROVIDE I.C.B.O.REPORT NO. ap y to an owner of property who bunds or improves Monson,"who contrvcte for such projects with a conmactods)licensed pureuent t0 the contractors License Law. ❑I am exempt under Sec. ,S a P.C.for this reamn PROVIDE MFGR.INSTALLATION SPECS. Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following dmanatbn: ❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation. Building m provided!for by Sectlon 3700 of the Labor Code,for the performance of the wok for which tale g perm)l is Issued. -seismic�qI haws entl will malnleln Workers Compensation Ineurence,as required by Section 3700 0l V Po th6 Labor Code,for the performance of the work for which this permit Is Imum.My Worker's -7 J� Companmibn Insurance carrier and Policy number are: .k...�� Total/2- 2- 2 Caroler ST-�F �/ Pmlcy No. ✓ /l 7 PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.00 This molten nem not be completed 11 the permit is for one hundred dollars($100)or IemJ3 / I certify that In the performance of the work for which this permit IS Issued,I Shall not employ —r fil any person in arty manner So as to become subject to the workers'Compemation Laws of call. All roofs shall be inspected prior to any roofing material being forma' I?I I Installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO APPUCANT: If,after making INS Certificate of Exemption,you should become Applicant understands and will comply with all non point subject to the Workers'Compeneatbn prWaons of the Labor Code,you must forthwith comply with such provisions or this permit Shell be dmmW revoked. source regulations. I certify that I have antl this application and state that the above Information Is coned.I epee to comply with all dry and county ordinamom antl stat°Imve relating to building wratmdbn,ark - All to co�S to a class or better. hereby euthofte representativas of this dry to enter upon the above-mentloned property for In- epmtbn purpose. ©� fWe)epee to Save,indemnify and keep harmless Uro City of Cupentic aaunt IlabIIHba, CT-31/ judgments,coek and expenses which may In erry wry accrue against mid City In consequence SIGNATURE OF APPLICANT DATE of the g of this permit. - . I . PRE-INSPECTION: ION: � * I PLYWOOD: ^ IN-PROGRESS: L INSP. DATE INSP. DATE 7 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