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5335E, OFFICE COPY PERM R- 5335. 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 180 DAYS FROM LAST CALLED INSPECTION, BUILDING ADDRESS ' 614?9 Ski KOV-D v' RESIDENTIAL_Z�COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA �� / / AIVA)� VES ❑ If yes I understand that. Class A NAME 0 �l1 s NO roof assembly is required. ❑ Initial I.C.B.O. # / pp ADDRESS_(0 r�AGP /ci 00-0 EXISTING ROOF COVERING PHONE — NUMBER OF EXISTING COVERINGS CONTRA R'S NAME e TO BE REMOVED ..5 TO BE RETAINED ADDRESSM TYPE OF ROOF COVERING CITU 8 ZIP , d�[ O f&JEXISTING PHONE 1[ 1 - / BUILT-UP ROOF El LICENSE I ASPHALT SHINGLES El LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license Is In full force and WOOD SHAKES ❑ ' effect. f�WOOD Class � / Lic. Number - Date LS_��—c%% ConiOTHER SHINGLES ElC-3License (SPECIFY) �� OWNER -BUILDER RATION et�J in hereby affirm that em exempt from the Contractors License Lew for the following reason. PROPOSED (Sec. i Business and Professions Code: Any city or county which requires a permit to construct, It applicant, alter, h pmva, demoto file signed statany ement structure, prior to Its issuance,pursuant to theprovirequires the of br such permit flaw a signed statement that licensed pursuant m the pro BUILT-UP ROOF of the the Contractor's a g it License Law (Chapter 9 (commencing with Section ]000) of of the 3 the ssanPo Business entl Professions Code) or that he Is exempt therefrom and the for the le for the alleged ASPHALT SHINGLES ❑ je is exemption. oft San fon h031.5 any for a permit subjects the applicant to Sicant e dull civilpelty of anally of not more than five by more undred (Swag.): , yeesdollars ❑I,es owner sthe property, employees or oesred wages asthdrsole compensation, will do WOOD SHAKES ❑ the work, and the structure Is not Intended tI to ded offered for sale Buenas and Profes- sions Cada: The Contractors License Lawdoesapply to or do n owner of property es, whobuildsWOOD thereon, and who does such work himself or through his own empbyees, Improve meet hiso own such SHINGLES ❑ improvements such Improvements are not Intended or offered for sale, It,ill however, the en of r or Improvement Is e r of provne not or forpurposetofstheowner-0ulberwallnavetheburtlanofprovingthemhatlld not build or Improve for purpose of sale.). OTHER (SPECIFY) ❑ ❑ 1, 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 Lew does not PROVIDE I.C.B.O. REPORT NO. apply to an owner of property who bulbs or Improves thereon, and who contracts for such projects with a contractor(a) licensed pursuant to the Contractor's License Law. I am exempt under Sec. ,B 8 C. for this reason El P. PROVIDE Ni INSTALLATION SPECS. Owner Dame WORKER'S COMPENSATION DECLARATION APVbICATION DATE VALUATION PERMIT FEE 1 hereby affirm under penalty of perjury one of the following declaration: An ❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compensptlgp ' as provided for by Section 3700 of the Labor Code, for the performance of the work for whic7T.1M3_ Y Building �' permit is issued. , / I have %� K �,Qj.� ❑ and will maintain Workers Compensation Insurance, as required by Section 3700 of Labor Code, for Seismic .the the performance of the work for which this permit is issued. My Worker's4(` Compensation Insurance carrier and Policy number are: (41 C� Total carriers- ddJ? .ALpn Policy No. Nl•3/�-GV //jpERMITAUTHORIZATION CE RTI FICA OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.E] xis) sisiDTE (This section need not be completed If the permit Is for one hundred dollars (51 00) or less.) 771 1 certify that In the performance of the work for which this permit Is Issued, I shall not employ 1 All roof.^ shall be inspected prior to any roofing material being any parson In any manner so as to become subject to the Workers' Compensation Laws of Call- forma. 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, alter making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply Applicant understands and will with all non point pp comply p y with such provisions or this permit shalCbe deemed revoked. source regulations. I certify that I have reed this application and state that the above information Is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and All roof coverings to be class "C"or better. hereby authorize representatives of this city to enter upon the above-menmaoned property for In. spection purposes. (We) agree to save, Indemnity and keep harmless the City of Cupertino against liabilities, QJ judgments, costs and expenses which may In any way accrue against said City In consequence ATUREO APPLICANT ATE 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