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R 4586 PERMIT R_ 4 5 8 6 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (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. 'E arovlu `9 RESIDENTIA COMMERCIAL OTHER OWN S , HAZARDOUSIR AREA NAM��J © ^ VQ YES O It taqheta Class assembly seuad NO Initial I.C.B.O.N ADDRESS— EXISTING ROOF COVERING PHONE 10 O I NUMBER OF EXISTING COV RINGS CONTR jOR'S TO BE REMOVED TO BE RETAINED NAM ADDRESSE OF ROOF COVER ING CITY&ZIPIP— ��(( )) C /,. EXISTING LICENSE PHDNE BUILT-UP ROOF NUMBER ASPHALTSHINGLES V LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 em Ilcensetl under provisions of Chapter a(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 aT Llc.Number Date 1 n - attar OTHER(SPECIFY) ❑ 1 NE uDER c PROPOSED I here's affirm I I am axem from the Contractors License Law for the followingreaso . (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to construct,alter,Improve,damollah,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(of a permit subjects the applicant to 4 JD 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 Profas. sions Code:The Contractors License Law does not apply to an owner of property who builds or "'l Improves thereon,and who does such work himself or through his own employees,provided that O.WODD SHINGLESWIY _ � $ such improvements are not intended or offered for sale.If,however,the building or Improvement �(�. G� v Is sold within one year of completion,the owner-builder will have the burden of proving that he did not build or Improve for purpose of sale.). OTHER(SPECIFY) ❑1,as owner of the property,am exclusively contracting with licensed contractors to construc(j rrV 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. C]t am exempt under Sec. ,B 8 P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT F E WORKERS COMPENSATION DECLARATION I hereby affirm undo penalty of perjury one of the following declaration: ❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building ppemit Is Is for by Section 3700 of the Labor Coda,for the pedormanceof the work for which this �/� `� ^ � g permit le Issued. �L/J ,/y $eISn11C ❑I have and will maintain Workers Comp cation Insurance,as required by Section 3700 of the L Oda,for ins performance of the rk for which t a permit la Issuetl.My Wor Co end n au n r and Policy n bar ere: ,1 I V Total ce r Poll U PERMIT AUTHORIZATIO DATE CERTIFICATE OF EXE PION FROM WORKERS' COMPENSATION INSURANCE N.C.0 (This section need not be completed If the permit Is for one hundred dollars($100)orleas.) I certify that In the performance o1 the work for which this permit Is issued,I shall not employ any person In any manner so as to became subject to the Workers'Compensation Laws of Dali. All roofs shall be inspected prior to any roofing r*terialibeing farms. installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. sueecct to Eh Workers' ft,after provisionis of CertificateLLaoCodde,you must srthwt become Applicant understands and will comply with all non point you must mrtnwnm comply P Y with such provisions or this permit shall application deemetl revoked. SOUfCB regUlatIODS. certify ith have read thistyorinancendstatethattheabove Information Isnstcorrect.ioagree to hereby uthoriellcity repesecountyofthiscesantloatelawsrelatingtobusdinguronstpertyfend All roof coverings to •lass"C"or better. if hereby authorize representatives of ihla city to enter upon the above-mentioned property for Ire epectlon purposes. L (We)agree to save,Indemnity and keep harmless the City at Cupertino against liabilities, • ludgmenla,coats antl expenses which may In any way accrue against said City In consequence of Ind granting df If permit. SIGNATURE OF APPLICANT 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