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R 5875 (2) PERMIT R_ 5875 . 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 R `fix 'NV' z/� . V 'a0" WPVe/ �''� RESIDENTIAL COMMERCIAL OTHER OWNER HAZARDOUS FIRE AREA NAME oS '.Q� k�� YES ❑ I.1 assembly starequire . ClassA 77KNO ❑ Initial I.C.B.O.N ADDRESS ) QZ Q D3 hf"rvu p (QC-e � - EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRA OR'S j1 NAME SI^"$ 7 �GO v 1 TO BE REMOVED - TO BE RETAINED ADDRESS 1 bs- I ( / }�(� TYPE OF ROOF COVERING CITY&PHONE ZIP— 1 Y J� EXISTING PHONE ` �3 —q4 BUILT-UP ROOF LICENSE � *22 NUMBER J�`� ASPHALT SHINGLES El LICENSED CONTRACTORS DECLARATION lice I hereby affirm that 1 em licensed under provisions of Chapter 9(commencing withSachin WOOD SHAKES vislon 7000)of Di3 of the Business and Professions Coda,and my license Is In lull force and effect. Q WOOD SHINGLES ElLlce s—�C J Lie.Numbs Data r r s Contractor OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I em exempt from the Contractor's License Law for the following reason. (Sec.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 El for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑ exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES Ej I,as owner of the properly,or my employees with wages as their sale compensation,will do ❑ the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profee. alone Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES Improves thereon,and who does such work himself or through his own employees,provided that ❑ such Improvements are not Intended or offered for sale.11,however,the building or Improvement pp lsaoId uild or prove for purpose setof sthe owner-builder will have the burden Of proving that he tlld OTHER(kPECIFY) ��p] FCA tP not build orioneyerofcompleio ,teJ. -t t/` E]1,as owner of the property,em exclusively contracting with licensed contractors to Construct IRA D E LC.B.O.REPORT NO. the project(Sec.7044,Business and Professions Coda:The Contractor's License Lew does not apply to an owner of property who builds or improves thereon,and who contracts for such projects ;�ENJ1IdRRp���t .INSTALLATION SPECS. with a contractor($)licensed pursuant to the Contractors License Law, BB I am exempt under Sec. ,B B P.C.for this reason Mi1pFj0VIy Owner Data PL_tyATJON�C1Alr- VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION ' I hereby affirm under penalty of perjury one of the following declaration: ' . ❑I have and will maintain a Certificate of Consent to salbinsura for Worker's Compensation, ,S Building as provided for by Section 370001 the Labor Coda,for the performance of the work for which this /) /7 ,^ permit Is Issued. �, L— (2 o 490 Seismic have and will maithe Performance Workerrmance6 f the work for Insurance,as required by d.My 3700 of ��k---!!! y ,the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's / Z Compensation lnauran ecarrlersntl Policy bar are: Total fCy Carder S���� F 0 Z Policy No. 12 4 6G 3 PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE NC.0 �y� (Tele fy than need not be once of the If the permit Is for one permit Is i dollars($100)or lees.) U [f 7 I certify that In the performance of the work for wrath this permit Is issuetl, shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being forma. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. become subject to the Workers'Compensation proviO APPLICANT: If.after sions of the lLabor Code,cate of Exemption, must forthwith comply Applicant understands and will comply with all non point with such provisions or this permit shapbe deemed revoked. Source regulations. I certify that I have mad 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 (—_AOof COVerin s 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, r / judgments,costs and expenses which may In any way accrue against said City in consequence of the granting of INS p8mul. IGNATURE 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 .