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R-5371 APPLICATION FOR cITY of cuPEHrINo NUMBEPERMIR R- 5371 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 1Be DAYS OF PERMIT ISSUANCE OR ' 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS J M OHTE ' 1 RESIDENTIA COMMERCIAL OTHER - OWNER'S HAZARDOUS FIRE AREA Y"n/ 7j': YES 0 If yes-I understand that a Class A NAME roof assembly Is required. / 1`105-71e Initial I.C.B.O.N EXISTING ROOF COVERING PHONE - NUMBER OF EXISTING COVERINGS CONTRACTOR'S �Uc �.( N TO BE REMOVED TO BE RETAINED NAME ADDRESS I ���� '/ TYPE OF ROOF COVERING CITY a ZIP S/.L r- T77. C?r�L EXISTING sPHONE 170BI �Y� '- 300 � SCDG`L BUILT-UP ROOF ❑ LICENSE NUMBER /,?03_5 ASPHALT SHI LES ❑ LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD S S 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and effect. WOODS I ❑ License Class G Lic.Number Oats alo leg Contrs� OTHER(SPECIFY E]� actor- GT_f? 'y C f VH UG OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that 1 am exempt from the Contractor's License Lew for the following reason. `�/ (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to $ w construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UPROOF 7 n❑ 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 if"hundred dollars($501 ❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD.SHAKES ❑ the work,and the structure Is not Intended or pushed for sale(Sea 7044,Business and Profes. sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES improve$thereon,end who does such work himself or through his own employees,provided that ❑ such Improvements are not Intended or offered for sale.II,however,the building or Improvement is soldwithin one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ not bulid 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 tloes 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 Contractor's License Law. PROVIDE MFGR. INSTALLATION $PFOB. F7 am exempt under Sec. ,B 8 P.C.for this reason Owner Data APPLICATION DATE 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 sell-insure for Worker's Compensation, Building G as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. Seismic ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of P -the Labor Code,for the performance of the work for which this permit is Issued.My Worker's Total Compensation Insurance carrier and Policy number are: .Carrier S7f4-7-E- p(7Ml-D Policy No. 6 p T 'RATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.I] (This section need not be completed it the permit Is for one hundred dollars($100)or less.) -'Lf,LKl iNV I certify that In the performance of the work for which this permit is Issued,I shall not employ 'I Ty any parson in any manner so as to become subject to the Workers'Compensation Laws of Ce16 All roofs Shal 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,alter making this Certificate of Exemption,you should become Applicant understands will I with all point subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP unerss ancomply y non with such provisions or this permit shalf,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 heisting to building construction,and All roof coverings to be class better. hereby authorize representatives of this city to enter upon the above-montloned property for In- spection purposes. /' (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, � Q n,� '(7 S I��lC CJ.3/� judgments,gran costa and expenses which may In any way accrue against said Clty,In consequence y� of the granting co of thisand permit. / SIGNATURE OF APPLICANT DA E 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