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00030071 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 100 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS -T V RESIDENTIAL COMMERCIAL OTHER O NER / HAZARDOUS FIRE AREA NAME �( �� !/ ( `�0����� YES ❑ II yes-I understand that a Class A � yr of assembly is required. p NO �/ Ini, I.C.B.O.N ADDRESS ✓� �7� EXISTING ROOF COVERING C PHONE Zi 7 3 ..a NUMBER OF EXISTING COVERINGS CONTRACTOR'S 1� ,, / r NAME Do/V i� l/Q / TO BE REMOVED TO BE RETAINED ADDRESS - TYPE OF ROOF COVERING . CITY&ZIP EXISTING PHONE BUILT-UP ROOF LICENSE NUMBER ASPHALT SHINGLES ❑ 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 force and effect. WOOD SHINGLES License Class Lic.Number Dal. Contra emr OTHER(SPECIFY) ❑ 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 requires a permit to construct,altar,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 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 live 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. 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 sob 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.). C 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS. C I am exempt under Sec. ,B&P.C.for this reason Owner Data APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Seismic ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit Is issued.My Worker's Compensation Insurance carrier and Policy number are: Total Carrier Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C❑ (This section need not be completed II the permit is for one hundred dollars($100)or less.) V U l(J 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 Date Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should became Applicant understands and will with all non subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp comply p y point with such provisions or this permit shall be deemed revoked. source regulations. I certify that I have read this application and state that the some information is correct.I agree to comply with all city and county ordinances and stale laws relating to building construction,and All roof coverings to /a of S atter. hereby authorize representatives of this city to enter upon the above-mentioned property for In- spection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, fir judgments,costa and expenses which may in any way accrue against said City in consequence SIGNATOR APPLICANT 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