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R 6626 . OBD PERMIT R_ 6626 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 RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA YES ❑ II yes—I understand that a Class A NAME iroof assembly is required. LS NO E] Iniffal- I.C.B.O.N ADDRESS � ) EXISTING ROOF COVERING PHONE. Z ,NUMBER OF.EXISTING COVERINGS / CONTRACT 'S - - TO BE REMOVED�TO BE RETAINED NAME ADDREss TYPE OF ROOF COVERING CITY.a ZIPS EXISTING RHO NP" r/ V� •T 71-070 7 BUILT-UP ROOF LICENSE q NUMBER �i! cJl ASPHALT SHINGLES ss J T LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ❑ 7000)of Divlalon 3 of the Business and Professions Code,and my license Is in full force and affeac, WOOD SHINGLES ❑ Llcenee Cla e` Up.Number 5 !K3 5 Data 2r)v contractor' OTHER(SPECIFY OWNER BUILDER DE Contractors License PROPOSED 1 hereby eHBuirm that 1 ani exempt from Professions the e: Any city License Lew for the following reason. (Sac.7ct,alt Business end olish,orrep Code: Any city or county which requires also a permit to construct,alter,Improve,to file signed or statem structure,prior is Its Issuance,also reproves the BUILT-UP ROOF appllcent for etch permit to ills a aptstatement that he Is Ilcanaetl pursuant to the provisions of me Contractor's License Lew(Chapter B(commandop with Section 7000)of Division 3 of the G • Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 2-0 !~ exemption.Any violation at Section 7031.5 by any appllcent for a permit subjects the applicant to e civil penalty of not more than five hundred dollars($500).): ys' C]1.as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES 'ppi the work,and the structure Is not Intended or offered for sale(sec.7044,Business and Profen . sionsCode:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES Improves thereon,and who does such work himself or Ih rough 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 at completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) - ❑ not build or Improve for purpose of sale.). ❑I,as owner at the property,am exclusively contracting with licensed contractors to construct the project(Sao, 044,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(a)ncensed pursuant to the Contramor'e License Lew. PROVIDE MFGR.INSTALLATION SPECS. [JI em exempt under Sec. ,e it P.C.for this reason Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE ' - .I hereby affirm under penalty of perjury one of the following declaration: ❑I have and will mentein a Certificate of Consent to self-insure for Worker's Compensation, // Bulldln U u as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Y /S/� / g permit Is tsetse. /? VJV Seismic have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 1 the abor Coda,for the performance of the work for which this permit Is Issued.My Workers - Cc pensatlon Ineurenre car er and Policy number ere: Total Carrier .`7�+C77— ':7"—A.. Policy No. ii`� PERMIT AUTHORIZATION DATE - CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.0 (This section need not be completed If the permit le for one hundred dollars($100)or lose.) D I certify that In the performance of the work for which this permit Is Issued,I shell not employ any person In any manner so as to become subject t the r am'Comps mion Laws of call- All roofs shall be irlyspected prior to any roofing material being fornla. installed. If a roof is installed without first obtaining an Data S q Appliaani inspection,I agree to remove all new materials for inspection. NOTICE APPLICANT: ll,after making this Certllica of Exemption,you should become A hcant understands and will cam subject to the Workers'Compensation provisions of the Le or Code,you must tortnwitn comply pp ply-with all non point with such provisions or this permit shall be deemed revoked. source regulations. I certify that l have read this appicailon and state that the above Information Is correct agree to comply with all city and county ordinances and state laws relating to building construction,end All roof C$$$��erin sto be cl$ess or better. hereby authorize representatives of title city to enter upon the above—mentioned property for In. //�� herebon uorizpurposes.r (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, judgments,costs and expenses which may In any way accrue against said Clry In consequence of the granting of this permit. SIGNATURE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY