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R 6064 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- 606 4 . REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (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 -2 Q-y O O r/"?, f02,f RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA ' YES ❑ It yes—I understand that a Class A NAMEroot assembly is required NO . ,®� Iniftl I.C.B.O.q ADDRESS 2 2 EXISTING ROOF COVERING PHONE f o r' / L NUMBER OF EXISTING COVERINGS ©evil CONTRACTOR'S NAME �• �N6ArL�S' BOO F. .eJ6 TO BE REMOVED O/f/ (,f TORE RETAINED V°tires ADDRESS TYPE OF ROOF COVERING CITY BZIP n r ,v -e--a'— &-7L/ e / 2,;t1/ti Al'- ✓• . EXISTING PHONE �� O B / 7 7 Q S�6 BUILT-UP ROOF F-1LICENSE NUMBER ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION s I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section OD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and affect. License Class �- LIC.Number 4,? / 7 y'(1 SHINGLES ❑ 8 Data 2 Contractor Y- 9�' 1 r..'t '7 , fin/ CrzcS OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractor's License Lew for the following reason, (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to construct,after,Improve,demolish,or repair any structure,prior to Its issuance.also requires the BUILT-UP ROOF ❑ spoil cant for such permit to rile a signed statement that he is licensed pursuant to the provisions . or the Contractors 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 e civil penalty of not more than five hundred dollars($500)): ❑I,as owner f the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑ the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes- sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOODS L Improves thereon,and who does such work himself or through his own employees,provided that ^ ❑ such Improvements are not Intended or offered for sale.If,however,the building or Improvement V is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER CIF not build or Improve for purpose of sale.). ❑1,as owner or the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVI I.C.ft@I�RORT NO. apply to an owner of property who builds or Improves thereon,and who contracts Mr such projects 4 4 ���� with a contractor(s)licensed pursuant to the Contractor's License Law. PROV MFGR.INSTALLARCIN CS. E]I am exempt under Sec. ,B$P.C.for this reason y Owner Date I WORKER'S COMPENSATION DECLARATION APPLICATION D —�—,V&LUATION�11 PERMIT FEE I hereby and under penalty of perjury one of the bellowing declaration:rWo have and will maintain a of the Lab or Consent toeperfor afor ofthe Worker's Compensation, O— L/� C�p O Q O Building as provided for by Section 3700 of the Labor Code,for the performance of thew for which this O /O permit Is Issued. ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 o1 Seismic Z the Labor Code,for the performance or the work for which this permit Is Issued.My Worker's Total Compensation Insurance carrier and Policy number are: Carrier S7"47`75" Fv/V O Policy No.%yr 77 J9—AP PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATIONINSURANCE N. �. (This section need not be completed II the permit Is for one hundred dollars($100C)Or lase.) J � ? C/'1) 0� 1 certify that in the performance of the work for which this permit is Issued,I shall not employ 1 O I any person in any manner so as to become subject to the Workers'Comp°nsanon Laws of Cali- All roofs shall be inspected prior to any roofing material being °`nia' !' / installed. If a roof is installed without first obtaining an Date Z 7 S➢ Applicant ^ 6 �6<� .� inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,alter making this Certificate Of Exemption,you s oultl become Applicant understands and will comply subject to he Workers'Compensation provisions of the Labor Code,you must forthwith comply PP pl with all non point with such provisions or this permit shall be doomed revoked, Source regulations. 1 certify that I have read this application and state that the above Information is correct.l agree to comply with all city and county ordinances and state laws relating to building construction,and All roof Coverings to be class"'IRItirbetter. hereby authorize representatives of this city t0 enter upon the above-mentioned property for In- spection purposes. p (We)agree to save,indemnity and keep harmless the City of Cupertino eg°Inst liabilities, - y,��P p'� 2- orof the granting sof his peand rmit ea whish may In any way accrue against said City In caneequence SIGNATURE OF APPLICANT 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