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R 5287 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 5287 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 [/ • wK2CM "CAH CIR,abv RESIDENTIAL COMMERCIAL OTHER NER'S n - HAZARDOUS FIRE AREA - YES ❑ If yes—I understand that a Clens A NA E root assembly is required. / NO ❑ Initial — I.C.B.O.B ADORE S 11 S • tr`' f r'►� EXISTING ROOF COVERING PHONE ✓_ ��i J NUMBER OF EXISTING COVERINGS CONTRACTOR'S �I7 ,NAME O W hC 4-- TO BE REMOVED; TO BE RETAINED ADDRESS TYPE OF ROOF COVERING CITY&ZIP EXISTING PHONE BUILT-UP ROOF NUMBER ASPHALT SHINGLES Q' LICENSED CONTRACTORS DECLARATION ' I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business entl Professions Code,entl my license le In lull force end effect. U(JrYy�7_ —Cs WOOD SHINGLES License Class Uc.Number a� DeOTHER(SPECIFY) � Date Contractor OWNER-BUILDERfromth DECLARATION PROPOSED I hereby affirm Bu Business am exempt from the e:Contractorscity License Lew for the following reason. �Y (Sec.7031.5,alter,improve, end Profedemolish, or re Code: Any Illy or county which Issuance, also requires requires permit e b applicconstruct,oruimprove,tlfile asigned air staeny mentrthate,priortoilel pursuant to thethe BUILT-UP ROOF 7 applicant for such permit to file a Cloned statement that g it licensed pursuant to the pro of the of sin Contractors License Lew(Chapter a(commencing with Section 7000)of for the 3 at the NOV• Business and violation of Code)or that he le exempt ant for and the Beare for the alleged ASPHALT SHINGLES 19gg exemption.Any violation of Section 7031.5 by any applicant fore permit subjects the applicant to / J e civil penalty of not more than live hundred dollars($500).): CITY[11,1,as owner of the property,or my employees with'weges as their Cole compensation,will do WOOD SHAKES CITyr Ur: LVI I the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Proles- M I tNU sions Code:The Contractor's License Law doss not apply to an owner of property who builds 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.If,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.). El I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(see.7044,Business and Professions Code:The contractors License Lew 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. ❑I am exempt un tl Sec. ,B d P,C.for this reason nwn"— � D t — APPLICATION DATE VALUATION PERMIT FEE ORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: gq A ❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Ifs Building as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this permit le issued. $eISR11C ❑ have and will maintain Workers Compensation IneulaOCe,as required by Section 3700 ofd &g 9 the Labor Code,for the performance of the work for which this permit le Issued.My Workers O©� gn Compensation Insurance carrier and Policy number are: Total Carrier Policy No+ C) I THORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.0 �j (This section need not be completed If the Permit Is for one hundred dollars(5700)or lees.) ( I 0 '7s'7V'1 tr certify that In the performance of the work for which this permit Is Issued,I shall not emptoy ' any person In any manner w ec to became subtest to the Workere'Compeneallon Lewa of l e All roofs shat a inspected prior to any roofing material being fernia. 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,cher making this Certificate of Exemption,you should become Applicant understands and will coin subject to the Workers'Compensalion provisions of the Labor Code,You must forthwith comply pP ply with all non point with such provisions or this permit shelgbe deemed revoked source regulations. I cenity that I have read 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 covering aclass"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. sp purposes. (We) (We)agree tos save,Indemnify and keep harmless the Cita ai Cupertino y Inagainstcon liabilities, judgments,coats and expenses which may In any way accrue against said City In consequence of the granting of this permit. F 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 0FFICE COPY