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R 5723 ERMIT APPLICATION FOR CITY OFCUPERTINO NUMBER R- 5723 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN/60 DAYS OF PERMIT ISSUANCE OR • 190 DAYS FROM LASTCALLED INSPECTION. BUILDING ADDRESS COalpnei RESIDENTIAL COMMERCIAL OTHER • owNER' HAZARDOUS FIRE AREA (u 21- 119-12 U I�VA VI 4(l.i')71i� VES ❑ If yes s I understand That a Claw A NAMEroof assembly is required. /1 NO ❑ Initial I.C.S.O.g ADDRESS 1031 C. ESItL{�S` � l -��?f' '1f'�� K�-- EXISTINGROOF COVERING PHONE -1O a a:!6 NUMBER OF EXISTING COVERINGS .I CONTRACTOR'S /I t e/y�(,;Ors 7 TO BE REMOVED TO BE RETAINED s NAMEj411 <.�C-U-s'1J �.Cr'V IY w1�Yr V ADDRESS � \ �f]��1yrr,� TYPE OF ROOF COVERING CITY&ZIP-" `" (�.. 'S� rj os �I T� EXISTING PHONE BUILT-UP ROOFLICENSE ❑ NUMBER ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION • I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and affect, 0139 © WOOD SHINGLES ❑ LicenseClass �j r� Lic.Number�� . . Date-7/!�/7 /) Contractor CJlL.6GC s 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 El for such permit to floe 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($500p): WOOD SHAKES ❑I,as owner of the property,or my employees with wages eirsoia sl1. Ido ❑ the work,antl the structure Is not Intended or offered for sale 7044 sand P alone Code:the Contractors license Lew does not apply to er of propertywho bullas er WOOD SHINGLES ❑ Improves thereon,and who does such work himself or ihroup nemployees,providetl roar such Improvements are not Intended or offered for sale.If,ho ve ih��bbygIph,�I qq Irrrr�@'a�prr�Ip is sold within one year of completion,the owner-builder will he a bur�frjd'pgraUn¢matla7d61 OTHER(SPECIFY) ❑ not build or Improve for purpose of sale.). ❑I,as owner of the property,am exclusively contracting will need cImme.oram construct 7 / C�C331'1'l l the project(Sec.7044,Business and Professions Code:The ontractor's License Law does not PROVIDE I.C.S.O.REPORT NO. apply to an owner of property who builds or Improves thereon, t�bp con tracts far such projects —r with a contractor(s)licensed pursuant to the Contractor's Lice a PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B B 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: / ❑1 have and will maintain a Certificate of Consent to self-Insure for Workere Compensation, /� Building Pprovided for by Section 3700 of the Labor Code,for the performance of the work for which this /JI (z� CQ�� Pei It Is Issued. 9 I h_'yJ•.7 Seismic )81 have and will maintain Worker's f the work fair Insurance,as required Is I by Section 370001 _C L four Code,for the performance of the work lar which this permit la Issued.My Worker's Compens n Insurance carrier and Policy number re: Total fit / � Carrier PollcyNo. lasb940PERMIT AUTHORIZATION DATE/FCAOFEXEMPTI � N FROM WORKERS' COMPENSATION INSURANCE N.C.❑ (This section need not be completed If the permit IS for one hundred dollars($100j 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 ea to become subject to the Workers'Compensation Law.of Can. All roofs shall be inspected prior to any roofing material being fornla. installed. If a root is installed without first obtaining an Date Applicant inspection,I agree to remove.all new materials for inspection. NOTICE TO APPLICANT: If.after making this Certificate of Exemption,you should become Applicant understands and will'com I 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 shalGbe deemed revoked source regulations. I certify that l have read this application and stela 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'i orbetter. _ hereby authorize representatives of this city to enter upon the above-mentioned property for In.specti - JuddIWon purposes. (We)agree s save,Indemnify and keep hay a y the City ai Cupertino against liabilities, of the printing costs and expenses which may In any way accrue against ealtl Clry in consequence of me granting of this permit. S ATU, APPLICANT DAT 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 -