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R-5578 PERMrr APPLICATION FOR 'CITY of cuPERTINo NUMBER R- 5578 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORD(IS NOT STARTED WITHIN 1W DAYS OF PERMIT ISSUANCE OR 190 DAYS FROM LAST CALLED INSPECTION, BUILDING ADDRESS RESIDENTIAL COMMERCIAL OTHER OWNER'S (� HAZARDOUS RE AREA NAME Par�OJC PIAz.:— IrU!\ YES ❑ If yes—I understand that ClassA roof assembly Is required. 0p /� t� �' /� � NO Initief I.C.B.O.Y ADDRESS0 7AGI��x- STuy'cs (L, rot• .251D 31'y d CWk EXISTING ROOF COVERING PHONE - Q / D NUMBER OF EXISTING COVERINGS 1 CONTRACTORS ,, (r ' NAME - .St ca I� �bt,h� 1/ �C. yyys TO BE REMOVED TO BE RETAINED ADDRESS .I� _ "�— TYPE OF ROOF COVERING crryazlP__ 1077 p \PL,,b5 A?,J ST '15-// 2- EXISTING PHONE y6p / 1-7( BUILT-UP ROOF NUMBER ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed ureter ptoyslons of Chapter 9(commencing with Section OOD SHAKES ❑ 7000)of Division 3 of the Business aro Professions Code,and my license s In foe torte met elle License Clams—_3 r 1.1c.Number 50 2 o q0 HINGLES ❑ - Date 11 -3.1 — 9 $ ContraGor N/I RWR &451cvL4 E ECIFY) ❑ OWNER-BUILDER DECLARATION �— I hereby affirm that I am exempt from the Contractor's Dcanse Law tor the following reason, (Sec.7031.5,Business arty Professions Code: Arty city or county which requires a perni t to G[,., wrrotrucl,eller,Improve,demolish,or ropelr arty structure,prbrlo Hs leeuence,also requires tet BUILT P01WF eppseem for much Permit to Ne a signed statement that he s)ban uad pursuant to the provisions of Me Contractees License Lew(Chapter 9(commencing with Section 7000)of Division 3 of Me Business and Professlors CCtle or that he IS exempt therefrom and Cts bass for the sllegetl ASPHALT SHINGLES ❑ exemption,Any Valetlon of Secllon 7031.9 by any applicant for a permit subjede the applicant to a dvO penalty of not more than five hundred dollars(5500).): P A C]1,as owner of the property,or my employees with wages as their sos compensation,will co WOOD SHAKES I D ❑ the work,and the structure L9 not intended or offered far sale(Sec.7044,Business and Praia �//pp - sions Code:The Contractees License Lav does not appy to an owner of property who bulks or WOOD SHINGLAV al' E:1Improves hereon,and who does such work himself or through his own employees,provketl Mat such Improvements we not Intended or offered for seta.If,however,the building or Improvement �/n✓��j� Is Said whin one year m completion,the owrwnbulldar will have the burden of proving Mat he did OTHER (SPCtiI- rot buetl or Improve for purpose of eels.). LVf ❑I,as owner of the property,am exciueyely,ccnirectlrig with Ibensetl contractors to conetrua the project(Sec.7044,Business and Professions Code:The Coniractor'e Llcenee Lew does not PROVIDE I.C.B.O.REPORT apply to an owner of property who bullde or Improves thereon,and who contract,for such projects MM a conirsctoge)licensed pursuant to Me Coatredoes ucense Lew. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B a P.C.M We reason Owner Date APPLICATIONDATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECIIAATION - I hereby affirm under penalty of woury erre of Me fallowing dedarwon: ❑I have and will melnl37 a of Ins ab of Consent to seerform for Workof Me Comperwh this BU' m 01 h etl for by Section an a d the Labor Coda,ton the performance of Me work for Compensation, Mb permit lave arat �4 $BIS ❑ have end will Memeintain Workerrmaryot f the,work for Insurance,as required by Section 3700 of 1 Me Labor Coda,for nc perfrier"sol the node for which this permit Is issued.My Workeea Compenmulbn InsurstKe carrier aro Policy number I ere: � ' Total Cerrler.� 1n6tL �CyYt n1'itn Policy No. '3'52 1 373 PE AUTHORIZATION DATE CERnFICATEOF EXEMPTION FROMWORKERS' COMPENSATION INSURANCE N.C.E) - (This settlor need not ae completed N he permit Is for one hundred dollars($100)or lase.) I certlN that M the performance of Me work for which this permit Is Island,I shell not employ .any person In any manner eo at,to become subject to the Workers'Cempensatlon Lowe of Cell- All roofs shallbe inspected prior to any oofing miteriarbeing fornla. installed. If a roof is installed without first obtaining an Date Appilcant inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: lf,after making Mie Certlfkete of Exemption,you shook become A licant unders n and will cos with all non point w h such prloylelo tsrsor,his permit al°e ae sued nthe Labor Iaxll °0de'y01 muel rorn'"mn e°`r�°N pp source regulation Pry I cars ty Mat I hove read Mb application and stele that the above Information le =1.agree to Comply with all city and coumy oralnances end slate laws relating to bulking conetmctl ,end DGINATURE oof coverings b class" "Or better. hereby authorize representatives of this dry to enter upon the abore-menllonad property kx Iry spectbn purposes. (We)agree to save,Indemnity and keep harmless Me Clty of Cupertino against 11alctiflee. L Judgments, tdgmen he n'ucow we IexpenL es� may In vry way accrue against said Clry In coneaquerics 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