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R 5190 PERMIT R_ 519 0 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR WI180 DANS FROM LAST CALLED INSPECTION. BUILDING ADDRESS RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA YES ❑ It yes understand that a Clam A NAME roof assembly is required. O ❑ Initial I.C.B.O.ff ADDRESS Q rn) A(AJ EXISTING ROOF COVERING �/f PHONE / 3 D NUMBER OF EXISTING COVERINGS / CONTRAC 'S _ TO BE REMOVED TO BE RETAINED NAME ADDRESS t/ /�N TYPE OF ROOF COVERING CITY&ZIP 7V EXISTING PHONE �` �// ' BUILT-UP ROOF ❑ LICENSE NUMBER CJ (O ASPHALT SHINGLES / LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES A 7000)of Dlvislon 3 of a Bu nese antl Professions Code,and my�liceennse le In full force antl Lien effect, (OWOOD SHINGLES T. License Cleae U..Number ®OT kcn ! Oats ContractorOTHER(SPECIFY) OWNER-BUILDER DECLARATIONPROPOSED CITY Ur k.0 I hereby affirm that I am exempt from the Contractor's License Law for the following reason. ' (Sec.703 1.5,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 t0 file a signed statement that he Is licensed pursuant to the provisions . of the Contractor's Livens Law(Chapter g(ommencing with Section 70001 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($500).): yy00D SHAKES ❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑ the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Profes. sions Cotle:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES Improve$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) ❑ not build or Improve for purpose of sale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(See.7044,Business���nnnd ProfesaIons Code:The Contramore License Law does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of properry w ry"""as Irimproves thereon,and who contracts for such projects with a contractor(s)licensed yllisuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec ,B&P.C.for this reason Owner Date WORKERS 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 ` aermitI for by Section 3700 of the Labor Code,for the performance of the work for which this / �� w _ �k g permit Is edforIssued. VsI I/•/'~V/ Cl I have and will maintain Workers Compensation Insurance,as required by Section 3700 of Seismic s the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's Compensatlo I sure ce car nd P cy number are: 7l /,, Total Carrier Polley No. ✓ v PERMIT A THORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE 100)o �O (Tele section need not r antecompletedof the If the permit is for one hundred dollars($100)or mplo 4 1 certify that in the performance of the work for which Ihie per It is issued,I shell not employ any person In an mann r so as to became subject tot war 'Compensation Laws of Cali. All roo s shall be inspected prior to any roofing material being fornia. (/p installed. If a roof is installed without first obtaining an Dela U Applicant inspection,I agree to remove all new materials for inspection. NOTICE APPLIANT: Te of Exemou shoul subject to theOWorrkeras'Compensation provisions ofafter maklnrthleethellLabor Code,cayolu mustforthwltlhaecome comply Applicant understands and will comply with all non point with such provisions or this permit shall be deemed revoked. Source regulAno I certify that l have read this application an elate that the above Information is correct.l agree to comply with all city and county ordinances eq ate Tawe relating to building construction,and All roof c0 class"O"Or betthereby authorize representatives of this city to enter upon the above-mentioned property for in- spection purposes. (We)agree to save,indemnity and keep harmless the City of Cupertino against liabllities,judgments,coats antl expenses which may In any way accrue against said Olry In consequenceof the granting of this permit. SI U CANT AT 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