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R 5831 - APPLICATION FOR CITY OF CUPERTINO . NUMB R R- 5831 REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR BUILDING ADDRESS 180 DAYS FROM LAST CALLED INSPECTION.qqPOC410L I L RESIDENTIALIV --COMMERCIAL OTHER OWNER'S ^V l 'D HAZARDOUS FIRE AREA NAME Td�I�li� y I YES ❑ Ifyes—Iunderaregthat. ClassA roof assembly is required. ADDp� ^` a�A,. !. /,O O Inlbal I.C.B.O.N SPSJC__A L ti Ir41 � wnS U�KIJ EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTUR'S NAM j 11LT- 7 Is TO BE REMOVED TO BE RETAINED ADDRESS /_r, f/� � !n S 59112- CITY TYPE OF ROOF COVERING . 8 ZIP l� �IC �cf71A JJJ / EXISTING PHONE&y1._ �� 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. 2 �) License Clas{��1��✓"Lic.Number 0 WOOD SHINGLES ❑ � > Dale �Z'�'9� Canirecto r OTHER(SPECIFY) ❑ G OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractors License Lew for the following reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires e permit to construct,sitar,Improve,demolish,or repair any structure,prior to its issuance,alsorequlres the BUILT-UP ROOF applicant for such permit to file a signed slatemenl that he Is licensed pursuant to the provisions of the Contractors License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the P7 n❑fy Business and Professions Code)or that he le 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).): ❑ ptlARI,as owner of the property,or my employees wages as their solo compensation,will do WOOD SHAKES ISr,D the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes. sions Code:The Contractors 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 WOOD SHINGLE M'Tv such Improvements are not Intended or offered for sale.If,however,the building or Improvement ar OF �UrtOl hVU Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) El bulld or Improve for purpose of sale.). [11,os owner of the property,em 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 contractor(S)licensed pursuant to the Contractor's License Lew, PROVIDE MFGR.INSTALLATION SPECS. C]i am exempt untler Sec. ,e 8 P.C.for this reason. Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penally of perjury one of the following declaration: '7 s r ❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Z� BUlldln ` as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g permit Is Issued. x��/l� ❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of �7 `/'�] V� $eISnII: the Labor Code,for the performance of the work for which this permit Is Issued.My Workers 3' I L 5 �CQ 9 Comp ation Insurance carrier and POIlcw number are: J Total r � Carrie PolicyPERMIT AUTHORIZATION CERT& KATE EXE PFROM WORKERS' COMPENSATION INSURANCE INSURANCE N.C.❑ (This eadlon need not be completed II the permit is for one hundred dollars($100)or less.) I certify that In the performance at Ne 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 Call- All roofs shall be inspected prior to any roofing material being forma' installed. If a roof is installed without first obtaining an Date Applicant inspection,I agre ova all new materials for inspection. NOTICE TO APPLICANT: II,ager making this Certificate of Exemption,you should become q licant under tends a Wlll Com subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply ply with all non point with such provisions or this permit Shell be deemed revoked. OU regulatlo S. I certify that I have read this application and state that the above Information Is correct.I agree to hereby authorize all cityandcounty ordinances and ter upon hela ing tobove- entingconstructlygand All r00 CO ring t0 ass"C" rbetter. hereby epurp se ropraeentallvae of this city to soler upon the above-mentioned property for In- spection purposes. Adlkhl ""''g.. to save,Indemnity and keep harmless the City of Cupertino against Ilabllilles, judgment.,costs and expenses which may In any way accrue against said City In consequence - ot the granting of this permit. S NAT E OF APPL CANT 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 .--