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R-6710 J PERMIT6 710 APPLICATION FOR ITY OF CUPERTINO NUMBER R- 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 RESIDENTIAL /\ COMMERCIAL OTHER OWNER'S n /y, HAZARDOUS FIRE AREA YES ❑ If yes—I understand that a Class A of assembly is required. NO j Initial I.C.B.O.N ADDRESS l 3D Y� • p�hQ� L�f' r" 1� V L EXISTING ROOF COVERING PHONE (O SV j " pO qtloql NU BER OF EXISTING COVERINGS r CONTRACTOR-S // fJ O ( • ,,, p©O TO BE REMOVED TO BE RETAINED NAME l� YY��„ ADDRESSZ C3 1 TYPE OF ROOF COVERING clry s zIP EXISTING PHONE / �(OZ f I - �C/! BUILT-UP ROOF ❑ LICENSE NUMBER C� G� / QUI 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 Professions Code,and my license is in full farce and effect. 2� WOOD SHINGLES ❑ License Class.S��Q.��Lt— Lic.Number �' Data / 6— / / 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 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 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 SHING • 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($500).): WOOD.SHAKES ❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑ the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes- sionsCode:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for sale.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) not build or improve for purpose of sale.). I,as owner of the property,am exclusively contracting with licensed Contractors to construct the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. IDE MFGR.INSTALLATION SPECS. I am exempt under Sec. ,B&P.C.for this reason Owner Date AP ATI TE TION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, uilding as provided for by Section 3700 of the Labor Cade,for the performance of the work for which this h permit is issued. JUL 9/�Q O F-1I have and will maintain Worker's Compensation Insurance,as required by Section 3700 01 U p ITx7(J G r Seismic f�, the Labor Code,for the performance of the work for which this permit Is issued,My Worker's Compensation • Compensation Insurance carrier and Policy number are: ��.�/ Y Total Zz$ Carrier Policy No.S(.tio 525 PORT61 ORIZAT ON DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.CQ (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 to any roofing material being fornia. installed. If a roof is installed without first obtaining an Data Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P with such provisions or this permit shall be deemed revoked. Source regulations. I certify that I have read this application and slate that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction.and All rOM to cll//aap"C"or better, hereby authorize representatives of this city to enter upon the above-mentioned property for in- Ol' - 6Y G herspeeby n purposes. (We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, �, judgments,costs and expenses which may in any way accrue against said City in consequence SIG ATURE OF A NT DATE of the granting of this permit. • 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