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R 6267 APPLICATION FOR CITY OF CUPERTINO NUMBER R- 6267 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 160 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. • BUILDING ADDRESS X 0397 S'e-o SC- l Tr �• '.) c°cl{�IerrNp RESIDENTIAL k� COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA NAME ��(t�'rV C�gl VES ❑ If yes s I assembly is and that a Class A roof assernmby Is required. - NO ❑ - India) LC.B.O.A ADDRESS, e1'���� EXISTING ROOF COVERING PHONE .L Sr 2• NUMBER OF EXISTING COVERINGS CONTRACTOR'S NAME 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 hereby affirm that I em licensed under erosions of e,and y(commencing In with Section WOOD SHAKES 7000)of Division 3 0l the Business and Professions Code,end my tisanes la In lull force and effect. WOOD SHINGLES License Class Lic.Number ' Date Contractor OTHER(SPECIFY) OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractors License Law for the following reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the -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 B(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 five 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- sionsw Code:The Contractor's License Law does not apply to an aner of property who build.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.IL however,the building or Improvement Is sold 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.). as owner of the property,am exclusively contracting with licensed contractors to construct ih pro act(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.L � apply to an owner of property who builds or Improves thereon,and who contracts for such projects with a contractogs)licensed pursuant to the CrR oes License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑I am exam funder S ,B&P.C.for this reason Owns Dete KER' �•14RATInw APPLICATION DATE VALUATION PERMIT FEE ereby affirm under penalty o erjury one off Ic lowin. ❑I have and will maintain a Certificate of Cone nit sell-Insure for Worker's Compensation, /) I Building �D as provided for by Section 3700 of the Labor Cotle, or 1 performance of the work for which this /I ' 1 //Vly jx' y permit is issued. 11Vn/ Seismic (O C1 I have entl will a sin Wo qua mpene 11 u es required by Sactlon 3700 of the Labor Cotle,for f erfar e we' r whi permit le Issued.My Worker's 'Compensation In to r f fief antl PoI cy number are: Total Carrier o. PERMIT AUTHORIZATION DATE J CE E E F ORKERS' COMPENSATION INSU N.C.I] (Thio aecllon ne�tl not be completed If the permit le for a unfired tlollare($100)or leas.) I certify that In fhb ped rmenca al ins work icor which this p mit Is IsauaQ I shall not employ any portion m any� « aim ^�• h ecLm-me-Wor fa'CemPenealmn Laws of cell. 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. NOT CE TO APPLICANT: ecome subject l0 the Workers'Compensation tion,after making ls o 1henLabor Code,cate of Exemption, must forthou withcomplyApplicant understands and will comply with all non point with such provisions or this permit shalgbe deemed revoked. - Source regulations. I certify that I have read this application and stale that the above Information Is correct.)agree to comply with all city and county ordinances and state laws relating to building construction.and All roof covering to be class rbetter. hereby authorize representatives of this city to enter upon the above-mentioned property for In. i e spection purposes. ! (We)agree to save,Indemnity and keep harmless the City of Cupertino epalnat liabilities, t l judgments,.costs and expenses which may In any way accrue against uald Cit.mnsequance • of the granting of this permit. SIGNA URE APPLI DA7 PRE-INSPECTION. PLYWOOD: IN-PROGRESS: INSP. DATE INSP.-DATE INSP. A TEAR OFF INSPECTION: BATTENS: - FINAL: INSP. DATE INSP. DATE INSP. DATE NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY.