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R-4631' APPLICATION FOR CITY OF CUPERTINO PE NU s'eR R- 4631 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 100 DAYS OF PERMIT ISSUANCE OR . 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS 1 ©s lh ek RESIDENTIAL' COMMERCIAL OTHER OWNER'S - HAZARDOUS FIRE AREA YES ❑ b yes-I understand that a Class A NAME roof assembly is required. 1 NO Inifial I.C.B.O.tt ADDRESS ��^s EXISTING ROOF COVERING PHONE /Z J �— 7 NUMBER OF EXISTING COVERINGS CONTRACTOR'S APIi OQ ( r ' �Y/QNQ -r� TO BE REMOVED TO BE RETAINED NAME ADDRESS sP-o G x 4-ill M 4q St-/ p� 4-PIE OF ROOF COVERING CITY a ZIP c�s�,�%J l I, ene, - � S> EXISTING PHONE 5 .26, —5-3 73 BUILT-UP ROOF ❑ LICENSE NUMBER - - 31 ASPHALT SHINGLES E] LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ]000)of Division 3 of the Business and Professions Code,and my license Is in full force and affect. _ WOOD SHINGLES ElLicense Class C-3 / Lic.Number 31 q Date Contractor �1�. C�o/'—__!/.�,;�• OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am 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 ❑ applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9(commencing with Section]000)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 live hundred dollars($5002): E]1,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- sionsCode:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ improves thereon,antl who tloes such work himself or through his own employees,provided!that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) El 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 with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. I am exempt under Sec. ,e 8 P.C.for this reason Owner Data APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: G" ❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation. B W lding Ili- as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ®/{p permit i9 issued. CI I3 �(� Seismic ❑ have and will maintain Worker's Compensation Insurance,as required by Section Worker's ,7n ,the Labor Code,for the performance of the work for which this permit is issued.My Worker's crf VP 95 Total Compensation Insurance carrier and Policy number are: L6 77, OO Carrier Policy No. PERMIT(AUTHORIZAT DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.0[] (. / (This section need not be completed if the permit is for one hundred 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 became subject to the Workers'Compensation Laws of Cali. All roof^shall be inspected prior to any roofft 1iJi fornia. n installed. If a roof is installed without first obta ning a Date I` lOApplicant -�-�� r dri. inspection,I agree to remove all new materials for inspectio . NOTICt TOAPPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point subject to the Workers'Compensation provisions of the Labor Code,you most forthwith comply pP P Y P with such provisions or this permit shalfbe deemed 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 refaling 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 kir in. spection purposes. (We)agree to save,indemnity and keep Harmless the City of Cupertino against liabilities, judgments,costs and expenses which may in any way accrue against said City in consequence SIGNATURE OF APPLICANT IDATE • of the granting of this permit. 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