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R-5561 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5561 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 OWNERS HAZARDOUS FIRE AREA VES ❑ If yes-I understand that a Class A NAME /roof assembly is required. NO I \ finii I.C.B.O.# - ADDRESS 41D6 EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS C� CONTRACTOR'S NAMEXf ,Ss - TO BE REMOVED TO BE RETAINED ADDRESS „ nO7 �(��/GO/� /,� TYPE OF ROOF COVERING CIN a ZIP L� EXISTING PHONE ��/f —d 6/�7 BUILT-UP ROOF ❑ LICENSE NUMBER r b ASPHALT SHINGLES LICE D ONTRACTORS D CLARATION I hereby affirm that I am licensed under provisions of Chapter g(commencing with Section WOOD SHAKES ❑ 7000)of Division 3 of the Business and Professions Code,and my license Is In full farce and /yy enact' /` WOOD SHINGLES License Class�L Lic.Number - — Date Contractor OTHER(SPECIFY) OWNER-BUILDER DECo PROPOSED I hereby affirm that am exempt from the Contractor's Dcenae for the following reason. (Sec.]031.5.Business and Professions Code: Any city or cou which requires a permit to construct,alter,Improve,demolish,or repair any structure,prior I 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 Contraclor's License Lew(Chapter g(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 \34 yam^ 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(5500).): PWQQD SHAKES A I [)I,as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes. sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES AUG 13 �+D Improves thereon,and who does 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 rrr�---llll is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFQJ'i Ut- not build or Improve for purpose of sale.). V Ul-C (VU 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 Lew 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 contmetor(s)licensed pursuant to the Contractor's License Levi. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B 8 P.C.for this reason Owner Dale WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: ❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building 1 :27 as provided for by Section 3700 of the Labor Code,for the pedormanco of the work for which this permit is issued. �('!�/� Seismic ❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of C,�/�/y�7 f�v” ©J the Labor Co f r the performance of the work for which this permit Is Issued.My Workers / Cl p -Compen ono I' urenc caI011.M �l Pmicy number are Total /27,311 a Carrier Policy PERMIT AUTHORIZATION DATE CERTIFICATE OF E MPTION FROM WORKERS' COMPENSATION INSURANCE N.C.❑ ' M ,!� (This section need not be completed if the permit Is for one hundred dollars($100)or less.) �v V ^ 1/ 1 X 3^ 7 I certify that In the performance of the work for which this permit is issued,I shall not employ CJ any person In any manner so as to become subject to the Workers'Compensation Laws of Ceti- All roofs shall be inspected prior to any roofing material being fornix. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,altar making this Certificate of Exemption,you should become A 'cant understands and will comply with all non point subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply p y p with such provisions or this permit shafte deemed revoked. OUr,Ce regulatlODS. I certify that I have read this application and state that the above Information Is correct.)agree i to comply with all city and county ordinances and state laws relating to building construction,and All co Brings to be class"C" 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, '^ judgments,costs and expenses which may In any way accrue against said City In consequence oI the granting of this permit. SGNA F 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