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R-5806 PERMIT APPLICATION FOR CITY of CUPERTINO NUMBER R- 5806 REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED i WITHIN 180 DAYS PERMIT ISSUANCE OR WI DAYSSFROM LAST CALLED INSPECTION. BUILDING ADDRESS RESIDENTIAI COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA YES ❑ I yes—I understand that a Class A NAME O - roof assembly is required. NO Initial I.C.B.O.# ADDRESS fY EXISTING ROOF COVERING PHONE' `L NUMBER OF EXISTING COVERINGS Qlti6 CONTRACTOR'S n/''� TO BE REMOVED TO BE RETAINED NAME �F" !/ Q•�Y ADDRESS CITU 8 ZIP EXISTING TYPE OF ROOF COVERING L // PHONE ,r 369- 99Z,/ BUILT-UP ROOFLICENSE ❑ NUMBER 633 ��S 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 effect. License Class -- Lia Number 63 3Y3 WOOD SHINGLES ❑ /Z—/G4—j' ,Qy9 (�. Si.� Date Contractor OTTER(SPECIFY) El OWNER-BUILDER DECLARATION PROPOSED hereby a#Bu that am exempt from the e: Any city License Law for the browing reason. (Sec.70315,Business and Professions Code: Any city or county which re,also a permit to construct,or such permitrove,tfiledemolish,signed statement anystructure,prier to its issuance,also requires the BUILT-UP ROOF applicant for such permit to file a Chain statement that g it licensed pursuant to the provisions of the Contractor's License Law(Chapter a(commencing with Section 7000)of Division 3 01 the • Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES exemption.pen.Any violation of than five 7031.5 by any applicant for a permit subjects the applicant to e civil penally of not more than five hundredy employees yellers(h wag): ❑Las owner structure cture i not i tended oyeffered wages as(Sec.their 44,compensation,snProfes- sions s- WOOD SHAKES ` the work,and the structure is not Intentlatl or a#entl for sale(Sec.7044,Business entl Profes- I signs Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ Improves thereon,any who does such work himself or through his own employees,provided that L176...� such Improvements are not intended or offered for sale.If,however,the building or improvement 1/I Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) �(I not build or Improve for purpose of sale.). t� ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct 2073 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 contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR. INSTALLATION SPECS. ❑1 am exempt under Sec. ,B 8 P.C.for this reason I� Owner Date APP NO VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby allirm under penalty of perjury one of the following declaration: �/. E]I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Y Buildin as provided for by Section 3700 of the Labor Code,for the performance of the work for which this vh perm) Is issuetl. $eISmIC have any will maintain Worker's Compensation Insurance,as required by Section Worker's of rC7 ©OO in Leber Code,for the fainperformanceWorker of the work for which this permit is issued.My Worker's yyj� Component Insurance carne �y Policy number are: �/ Total Carrier S� rr'N� Policy No. 13�� (.� y PERMIT AUTHORIZATION 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 Laws of call- All roots shall be inspected prior to any roofing material being fornia. 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: it,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp p y point with such provisions or this permit shall 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 bullying construction,and XNATCUOR ngs to be Class"C"or better. hereby authorize representatives o1 this city m enter upon the above-mentionetl property for In- ��/�� hereby purposes. (We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, judgments,costs and expenses which may In any way accrue against said City in consequence • of the granting of this permit. 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY