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R 5160 PERMIT R_ 5160 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 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS j0&39 A4-7-#4�san� ✓ RESIDENTIAL COMMERCIAL OTHER OWNER'S + HAZARDOUS FIRE AREA YES ❑ It yes I understand that a Class A —/ roof assembly is required. NO `yL Initial I.C.B.O.N ADDRESS ( ✓ �� �� EXISTING ROOF COVERING PHONE v (/ ( lQ^ Q NUMBER OF EXISTING COVERINGS / J CONTRACTOR'S �`—/� TO BE REMOVED TO BE RETAINED NAME C /� ADDRESS TYPE OF ROOF COVERING CITY&ZIP EXISTING PHONE BUILT-UP ROOF ❑ _ NUMBEa ASPHALTSHINGLES ❑ 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 Profesalone Code,and my license Is In full force and effect. WOOD SHINGLES ❑ License Claes Lie.Number Date Contractor OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractors 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 lasagne,also requires the BUILT-UP ROOF ❑ applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors 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($500).): E]1.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 offered for sale(Sec.7044,Business and Profes. cions Cods:The Contractor'sLicensesuch Law does elf or hisoapply to an own property es,whoidebuilds or WOOD SHINGLES Improves thereon,and who does such work reefed or.It,how his own employees,provided that ❑ such Improvements are not pled n,the offered for Bele. ill however,the en of pr or Improvement Is not dwltrI prove for purpose sthe ownerbulltlerwlll have the burden of proving that he tlltl OTHER(SPECIFY) not bulltl or Improve far purpose of sale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professors 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 contractor(s)licensed pursuant to he Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am empt under S ,B 8 P.C.for this reason E90sIIAT!!bA_V Data WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of penury one of the following declaration: ❑1 have and will maintain a Certificate of Consent to sell-Insure for Workers Compensation, Building as provided for by Section 3700 of the Labor Code,for me performance of the work for which this permit Is Issued. ^ Seismic thehave and will maintain Worker's Compensation Insurance,as required by Section 3700 of r the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's O r1 ©O C7+� Compensation Insurance carrier and Policy number are: ,1 199p Total Carrier Policy No. 'PERMIT AUTHORIZATION DATF. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.Ej (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 roofs shall be Inspected Prlor t0 any roofing material being fomla, 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: II,after making this Certificate of Exemption,you PPlicant understands and will comply should become A subject to the Workers Compensation provisions of the Labor Cotle.you must forthwith comply p y with all non point with such provisions or this permit shall be deemed revoked. source regulations. I certify that l 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 Wilding construction,and All roof coverings to be class"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. apection purposes. (We)agree tos save,indemnity smnity antl keep harmless the City of Cupertino against liabilities enc; of the granting costs and expenses which may In any way accrue against said City n consequence onnegranunpothis permit. SIGNATURE OF APPLICANT ATE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION I, OFFICE COPY