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R 5853 PERMIT ' APPLICATION FOR CITY OF CUPERTINO NUMBER R- 585 3 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT. (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 150 DAYS OF PERMIT ISSUANCE OR BUILDING180 DAYS FROM LAST CALLED INSPECTION. ADORES ��( �� ,' ✓D�l RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA - /—r�uf ���+✓u ,,,, Q YES E] If yes—I understand that a Class A NAME roof assembly is required. NO Initial I.C.B.O.B ADDRESS EXISTING ROOF COVERING PHONE. NUMBER OF EXISTING COVERINGS CONTRACTOR'S _q �,� TO BE REMOVED TO BE RETAINED NAME ADDRESS t'�C'(�?j Jn` L /9�� TYPE OF ROOF COVERING CITY&ZIP J J✓ !/ ! N! EXISTING PHONE q 9 Z _ BUILT-UP ROOF ❑ LICENSE NUMBER L ASPHALT SHINGLES ❑ ' LICENSED CONTRACTORS DECLARATION I hereby aglrm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES 7000)of Divislon 3 of the Business and Professions Code,and my licanse I n full force and Lice`' // L 7 WOOD SHINGL License Class `� Lic.Number " �" ❑ Date3-1Comractor� (�4n�t�y17LGCT OTHER(SPECIE ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec.7031 5,Business and Professions Code: Any city or county which requlres 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 to file a signed statement that he Is licensed pursuant to the provisions of the Contmetors License Law(Chapter 5(commencing with Section 7000)of Division 3 0l 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).): D SHAKES ❑1,as owner of the property,or my employees with wages as their sole compensation,will do WOO ❑ the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles- . sions Code:The Contractor's License Law does not apply to an owner of property who builds or 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-bulider will have the burden of proving that he did OTHER(SPECIFY) ❑ not 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 Professions Code:The Contractor's 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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B It P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE • WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: p O ❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, A Building U 77 as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is Issued. - ilii p •/ Seismic ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of WAR 1 r � the Labor Code,for the performance of the work for which this permit Is issued.My Workers may''/�/t Compensati I trier entl�licy number ere: n'y� D W`� Total Carrier R1l0 Policy No. �! C I r"PERMLTAUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.El (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 Cali- All roofs Shall be Inspected prior tcfany roofin material being forma. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all newimaterials for inspection. NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non OIDf subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply p y p with such provisions or this permit shellbe deemed revoked. source regulations. I certify that l have read this application and state that rho above information la correct.I agree �� to comply with all city and county Ordinances and state laws relating to building construction.and All roof Cover' sto be class"C°Or .better. hereby authorize representatives of this city to enter upon the above-mentioned property for In- spection purposes. (We)agree m save,Indemnify and keep harmless the City of Cupertino against Ilabllllles, '— judgments,costs and expenses which may In any way accrue against said City In consequence • of the granting o1 this permit. S AT'URE OF 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