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R 5570 MIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- 5570 REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WRHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS RESIDENTIAL COMMERCIAL OTHER OWNE /l/'�/� HAZARDOUS FIRE AREA. NAM �Tl�5Z� ( /7L/ Y YES ❑ II yes—I understand that a Class A roof assembly is required. NO Initial I.C.B.O.q ADDR s[rJ� �•�Q/I Q T EXISTING ROOF COVERING PHONE• — rJ NUMBER OF EXISTING COVERINGS CONTRACTOR'S /��0� i 2� TO BE REMOVED TO BE RETAINED NAME t ADDRESS #D5'1� a 9�O�LfL EXISTING TYPE OF ROOF COVERING CITY&ZIP PHONE BUILT-UP ROOF ❑ NUMBER 7.2I o2 32 ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and effect. WOOD SHINGLES ❑ License Class Llc.Number Date Contractor OTHER (SPECIFjM)'A I D ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractors License Law for the lollcavi son. rQ(g� (Sec.7031.5,Business and Professions Code: Any city or county which requires a p o R9 construct,alter,Improve,demolish,or repair any Structure,prior to Its issuance,also require BUILT-UP ROOF 1/ ❑ applicant for such permit to file a signed statement that he Is licensed pursuant to the provision ]�'(�� {,u of the Contractors License Lew(Chapter 8(commencing with Section]000)of Dm 10 ai he ASPHALT SHINGLESrtH (NQ Business and Prolemions Code)or that he Is exempt therefrom and the basis for Y0 etl exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the ap a to a civil penalty of not more than five hundred dollars($500).): /}t ❑ thatI,ea owner of the property,or my employees with wages as their aole compensation,wll WOOD SHAKES rk,entl the structure le not Intended or offered far sale(Sec.7044,Staff ae anal Proles- alone Coale:The Contractors License Law does not apply to an owner of property who bullda WOOD SHINGLES 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 Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) El build or Improve for purpose of sale.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Prolesslons Code:The Contractors 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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B&P.C.for this reason owner Date AP I TION DATE VALUATION PERMIT FEE V 1 SATION DECLARATION hereby ellirm untlar penalty of perjury one of the/allowing declaration: ❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which t s 4'— permit Is Issued. ,/fy..' .r ❑ have and will maintain Worker's Compensation Insurance,as required by Section 37000 VVD SeIS the Labor Coda,for the performance of the work for which this permit Is Issued.My Worker's `(/� �r Compensation Insurance carrier and Policy number are: F[r -Total Carrier PoIlcyNo. P MIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N C (This section need not be completed It the permit Is for one hundred dollars fill 00) or lase.) 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 Can- All roofs 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: If,after making this Certificate of Exemption,you should become Applicant understands an I with all non point Subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp Y p 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 an city and county ordinances and state laws relating to building construction,and All roof Coverings t0 eClasS" atter. hereby authorize rapt esenmtivea of this city to enter upon the above-mentioned property for In. ep on purposes. two, Z (Wen agree to save,Indemnity and keep harmless the Glry of Cupertino against liabilities, of Ipmarts,costa and permit. s which may In any way accrue against eeltl City In consequence onhe granting of this permit. SIG RE OF APPLICANT ATE PRE-INSPECTION: PLYWOOD: IN-PROGRESS: -r INSP. DATE INSP. DATE INSP. DATE TEAR OF INS ECTION: �—/ BATTENS: FINAL: INSP. DATES INSP. "DATE INSP. DATE NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION � . OFFICE COPV.