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R-6610s • 0 APPLICATION FOR REROOF PERMIT BUILDING ADDRESS /� /D/Go AI&MV )alta CITY OF CUPERTINO INSPECTION DIVISION (408) 777-3228 OWNER'S NAME.^�'JY ADDRESS /v" 5r' �?A'� PHONE �6.d)9'�� -8330 ADDRESS 2¢� 6� CITU 8 ZIP—� / '�J PHONE ,;217 I hereby aBlrm that I am licensed under provisions of Chapter 9 (commencing with Sec an 7000) of Division 3 of the Business and Professions Code, and my license is In full lone effect. License Class d39 Lic. Number l�aa7.3� Date Contractor OWNER -BUILDER DECLARATION 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 requires a permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance, also requires the 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 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).): ❑ 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 Profits. sions Code: The Contractor. License Law does not apply to an owner of property who builds or 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 not build 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 Contractors License Law does not 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. ❑ I am exempt under Sec. ,B & P. C. for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: [:11 have and will maintain a Certificate of Consent to sell -Insure for Worker's Compensation, as provided for by Section 3700 of the Labor Cotle, for the performance of the work for which this permit is Issued. ❑1 have end will maintain Worker'. mpensatlon Insurance, as required by Section 3700 of the Labor ode, i the pedormen of he work for which this permit is issued. My Worker's Compens tion In rahe pru rler and P011 y number are: arre: Carrier d0Ag, cGylcy N0. UZI CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.M (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. fornia. Date Applicant NOTICE TO APPLICANT: 11, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shell be deemed revoked. 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 relating to building construction, antl hereby authorize representatives of this city to enter upon the above-mentlonetl property tot in- spection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may In any way accrue against said City In consequence PRE -INSPECTION: PLYWOOD: INSP. DATE INSP. TEAR OFF INSPECTION: BATTENS: INSP. DATE _ INSP NUMBIT ER R- 66 10 PERMIT EXPIRATION PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCP OR RESIDENTIAL COMMERCIAL OTHER YES ❑ If yes — I understand that a Class A roof assembly is required. NO ❑ Initial I.C.S.O. k NUMBER OF EXISTING COVERINGS TO BE REMOVED % TO BE RETAINED a TYPE OF ROOF COVERING EXISTING BUILT-UP ROOF ❑ ASPHALT SHINGLES ❑ WOOD SHAKES [� WOOD SHIN " E^ i'L� JUN 1 6 Iggg BUILT -UPR F ❑ ASPHALT WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER (SPECIFY) ❑ PROVIDE I.C.B.O. REPORT NO. PROVIDE MFGR. INSTALLATION SPECS. �/ �y� /��n Building � gy,X Seismic /G1 Total .719,� PERMIT AUTHORIZATION — installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection. Applicant understands and will comply with all non point source regulations. All f coverings to b classic or better. ��Q� lSIGNATOR OF APPLICAN T DATE INSP. - FINAL: DATE NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION I OF FtCE COPY '