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R-5511 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5 511 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR ' 1BO DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS I S SQJ� RESIDENTIAL COMMERCIAL OTHER OWNER's HAZARDOUS FIRE AREA YES ❑ If yes—1 understand that a Class A NAMEaSeem by is required. NO - Initial I.C.B.O.X ADDRESS 1�51� �5' y� K���-ACS EXISTING ROOF COVERING PHONEy a.�.1 7 �'(- 17jC75 NUMBER OF EXISTING COVERINGS I CONTRACTOR'S /� A I TO BE REMOVED I TO BE RETAINED NAME Q.M. EFu'Y1=.IzPel- rit 1.�T ADDRESS TYPE OF ROOF COVERING CITY&ZIP �- 51 EXISTING PHUNE r+-F©9) p2aS_gA/&4 BUILT-UP ROOF ❑ LICESE NUMBER ASPHALT SHINGLES ❑ x' LICENSED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provisions of Chapter 9(Commencing with Section WOOD SHAKES 7000)of Dlvislon 3 of the Business and Professions Code,and my license is In full force and enact' WOOD SHINGLES ❑ License Claes Lic.Number OTHER(SPECIFY) ❑ Data Contractor >/ OWNER-BUILDER DECIARATION 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 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 ❑ 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. slons Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El 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 p y— Issoldwithinoneyearofcompletion,the owner-Wilder will he"the burden of proving that he did OTHER(SPECIFY) 1"I�TtAeCI-K. not 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 Lew. PROVIDE MFGR.INSTALLATION SPECS. ❑I em exempt under Sec. ,B 8 P.C.for this reason Owner Date APPLI T OV PETE .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 self-insure for Worker's Compensation, BUlldl g as provided for by Section 3700 of the Labor Code,for the performance of the work for which thisjuL permit Is Issued. 3RECD %, Oo- Seismic —� '• E]I havvand e end will maintain Worker's Compensation Insurance,as required by Section 371X)of Ty' the Labor Code,for the performance of the work for which this permit is issued.My Worker's �'I Compensation Insurance carrier and Policy number are: Ur LUNCfy"ry Total Carrier Policy No. PERMIT AUTHORIZATI DATE CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE N.C.❑ (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 become subject to the Workers'Compensation Law, el Call- All roofn shall be inspected prior to any roofing material being formla. �� � installed. If a roof is installed without first obtaining an Date I(a.19-1 Applicant .LY�,eeI/� Q inspection,I agree to remove all new materials for inspection. ` NOTICE TO APPLICANT: If,alter making this Certificate o xemption,you sho d became Applicant understands and will with all non point subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply comply P Y P with such provisions or this permit shalC be 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 relating to building construction,and All roof coverings to be class better. hereby authorize representatives of this city to enter upon the above-mentioned property for In- hereby purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, judgments,costa and expenses which may in any way accrue against said City...consequence SIGNATURE O APPLICANT DATE 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