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R-5564 MIT APPLICATION FOR clTv of cuPERTINo NUMBERR' 5564 INSPECTION DIVISION I PERMIT EXPIRATION REROOF PERMIT (408) 7T-322B PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. S BUILDING ADDRESS rr^r 0 � 1 � IT{rd, ' RESIDENTIAL COMMERCIAL OTHER OWNER'S l• - .'HAZARDOUS FIRE AREA ' /] 1 YES O If yes—I understand Btal a Class A NAME C `"' ` roof assembly IS required. InitialLC.B.O.M ADDRESS— C} e Q 1�"T1'CC^JAI" � EXISTING ROOF COVERING PHONE L�- L NUMBER OF EXISTING COVERINGS CONTRACTO 'S y'•` TO BE REMOVED - � TO BE RETAINED NAME ADDRESS ?) ©t Nymv Meda1� uyoZ� TYPE OF ROOF COVERING CITYB ZIP l/ f\— Z¢c�w�4 jtL" PHONE ``'' O J� I EXBILT- .. LICENSEr' 17 c� BUILT-UP ROOF ❑ NUMBER �`''� { 0 C.i� ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provddOna of Chapter 8(commencing with Section WOOD SHAKES ❑ 7000)of DMelon 3 of the Business and Professions Code,and my license� en7se la In full force an OffQ 3 � WOOD SHINGLES License Clave Q� Lk.Number ❑ Do.!%— I�— `r� ComrecMrAgiA (SPECIFY)OWNER-BUILDER DECLAPATION haretry affirm that am exempt Irom the Contractor.LkanseLaw the folbwing reeeon.(Sec.7031.5,Business entl Prete cions Code: Any city or count'wh h requlree a permit to cunstrud,after,Improve,demolish,or repair any structure.prior to its leauance,else requires the )OCER �,f ILT-UP ROOF ❑ applicant for III permit to file a signed Matemem that he Is licensed pursuant to the provisions of the Contractors License Law(Chapter a(commendwith Section 7000)of DMefon 3 01 the Busoehs end Professions Code)or that he Is exempt therefrom and the base for the alleged HILT SHINGLES ACL exampflon Any vioatlon of Section 7031.5 by any applicant for a permit eulosets the applicant to Ht 1--- e civil penalty,of not more than five hundred dollars(5500).): ❑l,as amen of the property,or my employees with wages as ther We compensation,will do WOOD AKES ❑ , the work,and the structure Is not Intended or offered for Bele(Sec.7044,Business and Proles. Blore Coca:The Contredoea License Lew does not apply to an Owner of property who builds or WOOD SHINGLES ❑' -Improves thereon,aro who time such work himaid Or through his own amp"",presided that sucn Improvements am not Intended or offered for sale.11,however,the building or Improvement Is sold wllNnweyear ofcompletion,theowner-builder will he"the burden of proving that hedid OTHER(SPECIFY) ❑ Mbulld or Improve for Wrpose of sale.). ' ❑I,as owner of the property,em"clusNely contracting with licensed contractors to construct NeProbd(Sec.7044,Business and Professkxa Code:The Contractors Ucerae Law dl not PROVIDE LC.B.O.REPORT NO. app y to an owner of property who builds lir Improves thereon,and who contracts for such projects with a contractor(s)Ilceneed pursuant to the Commences Uoense Lew. PROVIDE MFGR.INSTALLATION SPECS. ❑I am exempt under Sec. ,B&P.C.for this reason Owner Date APPLICATI• VALUATION PERMIT FEE ' WORKER'S COMPENSATION DECLARATION ! I hereby affirm under penalty 01 perjury cue of the following declaration: lx ❑I have and will maintain a Certlflcats 01 COosent to self-insure for Workers Compensation, BUII as provided for by Section 3700 of the Labor Code,for the performance of the work for which the A91Q 14 . permfI LT INLd aIssued. {/pM� Y $elSm ^�I have aro will maintain Workers Compensatlon Insurance,as required by Section 3700 of /� i La Code,fox the performance of the work for which the permit a Issued.My workers y�•�(` C«rgenaa�,U,gLn,InSu Qnw pleerr lentl F)pgcy number ere: I ���Q^C CITY OF IT AUT OR TOi81 Carrier ("r ([� Policy No PERMITAUTHORZAT - DATE CERTIFICATE OF EXEMPTION FROM WORKERS' •, COMPENSATION INSURANCE N.C{] (Thin sectlon need not be completed If the permit Is for one hundred delars(S100)or lees.) I tangly that In the performance of the work for which this pannit Is Issued,I shell not employ arty person In any manner w as to become su ed a t Workers'Compensation-awe of Cali. All roofs shall be Inspected prior to any roofing material being ferns' /1 installed. If a roof is installed without first obtaining an Date —(�_`� Appllcant inspection,I agree to remove all new materials for inspection. N TICE TO APPLICANT: If,after making this Cartlfkato of Exemption,you should become Applicant understands and will comply with all non point sub{sd to Ne Workers'Compeneetlon provisions of me per Code,you must forthwith comply PP P Y P with such provlaions or the permit shall be deemed r= source regulations. I certsy,that I have read this BPplkatbn aro Mete that Va above Information Ie correct.I agree to cempty with all dy,and county ordinances and state awe relating to building construction,and All roof COvrings to be class"C"or better: • hereby authorize repraeentatNee of this city to enter upon the above-menifoned property for In- r•q 1 _ /S spection purposes. (YJ ` L_A\• (We)agree to save,Indemnity and keep harmless Ilse City of Cupertino apasst Ilebllllles, - ptlpmento,wee and expenses wNon may In env way acaue against sold Cit In consequence .11 l tFSIGNATOR OF APPLICANT - DATE PRE-INSPEECC • e of Na permit, TION: PLYWOOD: IN-PROGRESS: INSP. DATE INSP. DATEINSP. DATE TEAR OFF INSPECTION: �fe+ BATTENS: FINAL INSP. DATE INSP. DATE' INSP. DATE NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION' OFFICE COPY