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R-5425 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 5425 REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED • WITHIN 180 DAYS OF PERMIT ISSUANCE OR BUILDING ADDRESS 180 DAYS FROM LAST CALLED INSPECTION. OWNER'S L RESIDENTIACOMMERCIAL OTHER ' I t .-] s j�Q� HAZARDOUS FIRE AREA NAME Mk / Y If yes—I understand that. — Class A L� roof assembly is requiretl. ADDRESSI l] 1 Y L , NO IM l I.C.B.O.k (41 �" E, SIS / ZL EXISTING ROOF CUM RING PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S /T NAME_ I� I r � t TO BE REMOVED TO BE RETAINED ADDRESS F CITY azlP f TYPE OF ROOF COVERING ra`�� S 1�� -F- Sr V< astlz q EXISTING LICOENSE NE­� LOA � ` �r `��D BUILT-UP ROOF NUMBER cySZ©/ Q ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under or talons of Chapter 9(commencing with Section WOOD SHAKES ]000)of Division 3 of the Business and imfesalans Cotle,end my license Is In full farce and effect. WOOD SHIN�LE S4 El /OLicense Cles Uc.Number ,,((C�ee A�— IS Dare LR-13UIL 't OTHERI{SPECIFYeqOWNER-BUIL RDE ATIO yI � /khereby affirm that am exempt from Co Con rector License w for the following reason, PROPOSED rec.7031.5,Business and Professions Code: Any ci wMch requires e permit to Lvh construct,altar,Improve,10 file sl nee arepairto structure,prior to its issuance,also requires the BUILT-UP ROOF applicant for such permit Io file a signed statement that he is licensed pursuant to the provisions ' of the Contractor's License Lew(Chapter 8(commencing with Section 7000)of Division 3 of the Business and Professions Code)or Ihat he Is exempt the Ir and the bests for the alleged ASPHALT SHINGLES /G exemption.Any violation of Section]031.5 by any appl lcant far a permit subjects the applicant to a civil penally of not more than live huntlrad dollars($500).): x 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- slons Code:The Contractor's License Law does not apply to an owner of property who builds or ^ Improves thereon,and who does such work himself or through his own employees,provided that WOOD SHINGLES 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 not build or improve for purpose of sale.). OTHER(SPECIFY) ❑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 Contractors License Law. ❑I am exempt under Sec. ,B B P.C.for this reason PROVIDE MFGR. INSTALLATION SPECS. 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 maintain a Certificate of Consent 10 self-Insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code,for the performance of the workfor which this Building permit is issued. q �x p sq,�have and will maintain Workees Compensation Insurance,as required by Section 3700 of q 9) I 1 Ott OC' Seismic _the Labor Coda,for the performance of the work for which this permit is Issued,My Worker's I Compensationinsurancein,s�u`a�nce[cp}vier and Policy number are: '/ Total Darner ` ^��`3trC Policy No. :72L `c1-f PERMIT RIZATION CERTIFICATE OF EXEMPTION FROM WORKERS' DATE COMPENSATION INSURANCE N,C.I] (This section need not be completed It the permit is for one hundred dollars($100)or less.) I certify that In the performance of the work for which this permit Is Issuetl, shall not employ any person In any manner so as to becomes o orkar'C mpensation Laws of Cali- All rOOf•^•she b insp cted prior to any roofin material being forme. Date ZR installed. If a roof is installed without first obtaining an Appllc I inspection,I agree to remove all new materials for inspection. NOTI TO AP LICANT: If,eller kin C Iflce o Exe n,you should become subject 1 the Wor ere'Compensation pr inions of the Labo otle,you must forthwith comply Applicant unganwIlth.al' ply with all non point with such provisions or this permit ahalCbe tleemed source regula I certify that I have read this application and state that the above information Is correct.I agree to comply with all city entl county ordinances and state laws relating to building conalructlon,and All cc en etter.hereby authorize representatives of this city to enter upon the above-mentioned property for In- spection purposes. (We)agreetoneve,Indemnity and keep harmless the City al Cupertino against liabilities, 1 ZQjudgment., oatsand expenses which may in any way accrue against said City In consequenceof the granting o1 thispermit. D EPRE-INSPECTION: PLYWOOD:INSP. DATE INSP. DATE ATETEAR OFF INSPECTION: BATTENS: INSP. DATE INSP. DATE INSP. DATE NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION - - OFFICE COPY -