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R-5773 ' N-ERMIT APPLICATION FOR CITY of cuPERTINo. UMBER R" 5773 , INSPECTION DIVISION PERMIT EXPIPR e '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, RESIDENTIAL COMMERCIAL OTHER OWNER's HAZARDOUS FIRE AREA ' YES ❑ B yes-I understand that a Class A NAME �o •`© root assembly Is required. S9/4 (�Q NO ❑ ROOF LG O. ADOREss EXISTING ROOF COVERING 3 7-a / PHONE .5 --� O O - NUMBER OF EXISTING COVERINGS CONTRACTOR 64-96-11415 -7-us`nr3 O� - TO BE REMOVED / TO BE RETAINED NAME �-ti cr ,�T . ADDRESS f Q n O �/ _/ Q a t TYPE OF ROOF COVERING CITY&ZIP o2 EXISTING PHONE p$�G o A—9'Z 3.3 � � BUILT-UP ROOF ❑ SE NUM ER / ASPHALTSHINGLES El LICENSED CONTRACTORS DECLARATION hereby affirm that I em uceneetl under fe sions o/Chapter y(commencing with"Sectionand WOOD SHAKES - ]000)of DNleion 3 of the Buslmee end Professions Code,end my license b In full tome end effe'' WOOD SHINGLES ❑ ucense Cl eea C' 9 tic.Number �S/ 3 / OTHER(SPECIFY) ❑ Date 4xj Coniredor OWNER-BUILDER DECLARATION/ rPROPOSED p I hereby affirm that I em exempm t frothe Contractors Llcenes lath w for e following res (Sac.7031.5,Business and Proleaslona Code: Any dry a county which requires a per to construct,after,Improve,demolish,or repair any structure,prior to as lseuarpe,also requires the BUILT-UP ROOF O ^� applicant for such permit to Ilio a signed etatemertt that he is licensed pursuant to the prwlslorm • of the Contractor's License law(Chapter B(commencing with Section 7000)of Olvislon 3 old pHALT$H AG e/ Business and Professions Coca)or that he Is exempt therefrom and the breis for the aIle civ exemption.Any rotation of Sectlon 7031.5 by any applcam for a permit subjects the applicant to 11 lir LIB •�l) t a chill penalty of not more than five hundrad dollars v�Jt ttta�wak d tiof eb cproperty, ep srnollnt Meda oo a with a as thesole ir BuNnee f w fro e: �� D SHAKESG V 2aL.wt alone Cede:The Comrector'e License Law does not apply to an owner of pnoperty,who bulks or WOOD SHINGLES Improves thereon,and who does such work hlmse8 or through his own employees,Provided that ❑ such Improvements are not Intended or offered for sale.It,lft awtr,the building or Improvement Ia add witliln ona year of completion,the owner-bulkier will have the burden of proving that he did OTHER(SPECIFY) not build or Improve for purpose of sale.). ❑I,as owner of the property,am eadushely,contracting with Ikorroe0 coniraclon to construct the project(Sec.7044,Business and Prolan nn" the Contractors-cense law does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of property who builds or improvise thereon,and who commons for such projects . with a contractor(s)licensed pursuant to the Contractors license law. - PROVIDE MFGR.IN$TAL)_AATICN SPECS. C]I em exempt under Sec. ,B 6 P.C.for ihls r. Diviner Date WORKER'S COMPENSATION DECLARATIpJ APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the bllowing declaration: ❑ haveand willmelnt3in 7a of Me Labor Consent to MeperInsurebr of the oCompensetlon, /'�� - �� Building 1q7, as pII thav lot by ill main 3700 of Me Lab or Codelot thepe-Insur forcur Worker, work Cor omparison", hthis !// Permit is issued. �� Seismic ❑I have and will maintain Workers Comperoetbn Insurance,as;required by Section 3700 of the Labor Code,for the performance of the work far which this permit Is lf,ued.My Workers -Compener on I� mancem �e�r end Poallry number are: Total Carrier i Palk;y No. e�0 7 —98/Y/b PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C{] T^ (This section need not be completed If the permit Is for one hundred dollar,($100)or less.) . l 0(F I certlty that In the performare oof the work for which this porn it 15 Issued,I shell not employ '` JCJ any person m a manner w ra to become subject to the Workers'Comparsatlon laws of Can. All roofs shall be inspected prior to any roofing material being fornia. L .30 9p .• installed. If a roof is installed without first obtaining an Data Applicant —�_ inspection,I agree to remove all new materials for inspection. NOTICE TO APPUCANT: II,after making thio Certiecej of Exemption,you shouts become Applicant understands and will comply with all non point subject to the Workers'Compensation provision d the Labor Cade,you must torthwah comply with such provislonB or this permit shel¢be deemed revoked, source regulations. I cert,y that I have read this application and state that the above Intormation Is correct.I agree to dumpy with all or,and county ordnences and state Tawe hoisting to WIWInQ canetructlan,and All roof Coverings to be class or better. hereby auup o e representatives of This city to enter upon the shwa-manibned property for In- spaufton (We)agree tohwelava, Indemngy land keep harmsew the City of Cupertino apalnst Ilabllllim, jucip,rents;wets arta expenses which may In any way accrue against veld City In consequence SIGNATURE APPLICANT DTE In- of ta Wanting of this permlL 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 —�