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R 5924 SS � • ! PERMIT q_ 5 9 2 4 . 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 Dean22 3 RESIDENTIAL COMMERCIAL OTHER OWNER'S (K� / HAZARDOUS FIRE AREA NAME /_\�/1 � e� �) YES ❑ If yes-I understand that a Class A, roof assembly is required. NO ❑ Initial I.C.B.O.If ADDRESS EXISTING a EXISTING ROOF COVERING PHONE / /LO l Into NUMBER OF EXISTING COVERINGS CONTRACTOR'S 'I�n NAME--/— fir)) S `/�'y �d-ti' •` o �Ih 0� TO BE REMOVED TO BE RETAINED ADDRESSR / TYPE OF ROOF COVERING CIN 8 ZIP—PA. .-8 X Los — EXISTING PHONE BUILT-UP o_�� •� BUILT-UP ROOF ❑ LICENSE NUMBER ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION hereby affirm that I em licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES 7000)of Division 3 of the Bu6lnaes and Professions Code,and my license le In full force entl Liceffense '////fffr� �Q`-x�Qnz 7253y / WOOD SHINGLES ❑ Llconae Cleee(�'J / Lic.Number 7•J fO OTHER(SPECIFY) ❑ Date Contractor _ OWNER-BUILDER DECLARATION PROPOSED hereby affirm that I am exempt from the Contractors License Law for the following reason. IS 7031.5,Business and Professions Code: Any city or county which requires a permit to construct,alter.Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑ applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Lew(Chapter B(commencmg with Section 7000)of Division 3 of the El and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES exempllon.Any violation of Section 7031.5 by any apploare for a permit subjects the applicant to a civil penalty of not more than live hundred dollars($500).): ❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes- elons Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES Improves thereon,and who does such work himself or th rough his own employees,provided that ❑ such Improvements are not Intended or offered for sale.If,however,the bullding or Improvement Is sold within one year of completion,the owner-builder will have the burden of proving that he do OTHER(SPECIFY) ❑ not build or Improve for purpose of sale.). ❑I,as owner of the property,am exclusively contracting with licensed 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 who builds or improves thereon,and who contracts for such projects q with acontlicensed pursuant to the Contractor's License Law. ❑ exempt PROVIDE MFGR.INSTALLATION SPECS. I em exampt antler Sec. ,B 8 P.C.for Ihle reason OwnerDate WORKER'S COMPENSATION DECLARATION OA P c C TION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: E]I have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, �/n �� g as provided for by Section 3700 of the Labor Code,for the performance of the work for which this " Bui din permit Is issued. Seismic ❑I neve and will maintain Workers Compensation Insurance,as required by Section 37 �'•V � s the Labor Code,for the performance'yof the work for which this permit Is Issued.My Workers Compen�g9jp�tlon Insurance carrier enr��Ilc}�J/•�n�u��m.b//99��r,�,�re: VrCl7ljly /0d Total Carrier/ '�YJer)car,=Policy No, BRo.S[�19S-,p PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' 'COMPENSATION INSURANCE N.C.I] (This section need not be completed if the permit Is for one huntlretl dollars($100)or less.) 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 Workers'Compensation Laws of Can- All roots snail be inspected prior to any tooting aterla eing fornix. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. NOTICE become subject to theO orrkeres'Compense ion pro0slonis of thecate of LaborCode,Exemption,u must forthwith comply Applicant understands and will comply with all non point with such provisions or this permit shall be doomed revoked. source regulations. I certify that I have read this application and state that the above Information is correct.I agree to comply with all city and county ordinances and state laws relating to building Construction.and All roof coverings to be class"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In- spection purposes. (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, 2p..�,( 7.7-1-rd, judgments,costs and expenses which may in any way accrue against said City In consequence of the granting of Imo permit. SIGNATURE OF APPLICANT V 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 _