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R-5347 PERMIT R_ APPLICATION FOR CITY OF CUPERTINO NUMBER 5347 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 - PERMIT EXPIRES IF WORK 15 NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS //.Q� 7,-41" RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA /� – C-�f ' l7�( r VES ❑ If yes—I understand that a Class A NAME �((( ( /K� roof assembly is required. � 1401ii!io Initial I.C.B.O.A ADDREss � ( �jlr�� .��?'J� EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S ! NAME TO BE REMOVED TO BE RETAINED ADDRESS TYPE OF ROOF COVERING ' CITY s zIP 47z�ti y ��(�1 � ��S EXISTING PHONE — BUILT-UP ROOF ❑ LICENSE NUMBER / ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter B(commencing A.4hn WOOD SHAKES ❑7000)of Division 3 of the Business and Professions Cotle,antl my license is inf effect. [7 WOOD SHINGLES ❑ License Class �� L Lic.Number ��-/�� ( Date �'– -q�T Convector THER(SPECIFY) ❑ OWNER-BUILDER DECLARATIx� � OSED I hereby affirm that I am exempt from the Contractor's License Law for tine lollawin ason. (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 requlresahe U1 -UP ROOF ❑ applicant for such permit to file a signed statement that he is licensed pursuant to the provisions jC of the Contractors License Lew(Chapter 9(commencing with Section]000)of Division 3 of the Business and Professions Code)or that he is exempt therefrom and the basis for the altered 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).): ❑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 offered for sale(Sec.7044,Business and Profes- sionsCode:The Contractor's License Law does not apply to an owner of property who build.or improves thereon,and who does such work himself or through his own employees,provided that WOOD SHINGLES ❑ such Improvements are not Intended or offered for safe.If,however,the building or improvement is sold within one year of completion,the owner-builder will have the burden of proving that he didOTHER(SPECIFY) El 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 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 conlractons)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS. I am exempt under Sec. ,B 8 P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I her affirm under penalty of perjury one of the following declaration: 0� p /p�•k/ eve and will maintain a Certificate of Consent to self-insure for Worker's Compensation, {{''�_ M BUIdm as provided for dyill Section maintain a of the Leber Code,for the performance for Worker's compensation, which this enation, - permit is issued. APA „ www Seismic I have antl will maintain Workers Compensation Insurance,as required by Section 3]OO of R f 7 ////ssks��.... l� the Labor Code,for the performance of the work for which this permit is issued.My Worker's �A _\7 D 'Compensation Insur��,n[ce�cerrler antl Policy nu bar are: �T 1!! O Total Carrier L "��_�jr PolicyNo.OLT *V=Q�i p 1Q' HORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.❑ (This section need not be completed if the permit Is for one hundred dollars($100)or less.) 1 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 +-e �� Data--�� Applicant inspection;I agree to remove all new materials for inspection. NOTICET AP LI ANT: IL after making is Certifi ode, n,must should hwit become Applicant understands and will I with all non subject to the Workers'Compensation provisions d lin aver Code,you must forihwllh comply PP ply point with such provisions r this permit shation deemed that the $OUfCe regulations. coplly that have read this application and state theatheabove information iscorrect,lagree herebyto uthofiallcity pesecountyofthiscesantlstate laws teruonthelabarve- entingconspertyfend All root coverings to be cls s" better. hereby authorise representatives of this city to enter upon the above-mentioned property for in- ,x apectlon 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 of the granting of this permit. SIGNATURE F APP DAT 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