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R-5693 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBERR- 5693 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 160 DAYS OF PERMIT ISSUANCE OR 100 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS RESIDENTIAL—ZCOMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA VES ❑ If yos—I understand that a Class A NAME `I roof assemlNy is required. �— NO Initial I.C.B.O.N ADDRESS 1 O 3 V ( S+X N J EXISTING ROOF COVERING PHONE 11 1 - 7`7 NUMBER OF EXISTING COVERINGS C9 CONT d e1I 0S I D TO BE REMOVED O� TO BE RETAINED NAME/ // T ADDRESS S-6 L N rl S� SGN .5 Se Ga, TYPE OF ROOF COVERING CITY&ZIP c� —7 EXISTING PHONE 4 0 >S �q53�- L '� BUILT-UP ROOF LICENSE NUMBER - / ASPHALT SHINGLES 10LICENSED CONTRACTORS DECLARATION I hereby affirm that I em Ilcensed under provisions of Chapter 0(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 ]l^ License CIe39 Llc.Number y Dote Contractor OTHER(SPECIFY) ❑ C OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to soplicart.eller,improve,demolish,sign dstaement that Is licenses Issuance,to so the BUILT-UP ROOF —I / applicant for such prove,to file ah,or re air an structure, that he le for to its al the provisions 141--I//// of the Contractor's License Law(Chapter g(commencing with Section 7000)of DIA 910n 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).): WOOD SHAKES El I,as owner of the property,or my employees with wages as their sole compensation,.111 do the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profen Maine Code:The Contractor's License Law does not apply to an owner of property who builds or WOODSHINGLES El thereon,and who does such work himself or through hes own employees,provided that such Improvements are not intended or offered for sale.11,however,the building or Improvement is sold within one year Of completion,the owner-builder well have the burden of proving that he did OTHER(SPECIFY) ❑ not build or Improve for purpose of sale.). ❑I,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 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 conimctor(9)licensed pursuant to the Contractor's License Law. PROVIDE MFGR. INSTALLATION SPECS. ❑1 am exempt under Sec. ,B B P.C.for this reason Owner Data APPLICAT19N DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: _e� ❑I have and will maintain a Certificate of Consent to sell-insure for Workers Compensatlon, ty/ t® Building I u't as provided for by Section 3700 of the Labor Code,for the performance of the work for which this I _ permit is issued.an r� �� �^ Seismic❑I have end will the performance Worker's Compensation the workfor Insurance,e9 required by Section 3700 of the Labor Cotle,for the performance of the work for which this permit is Issued.My Workers `. Total 'Compensation Insurance carrier and Policy number are � (/�, carder Policy No. PE Myf AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N. (This section need not be completed If the permit Is for one hundred dollars(31 Or lees.) I certify that in the performance of the work for which this permit Is Issued,I shall of employ any parson In any manner so as to beona,cuClac4bTB Workers'Comp sedan All roofs shall be inspected prior to any roofing materi I being ^ installed. If a roof is installed without first obtaining an Date • • l Applicant � inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: Isubject to the Workers'Compentl saeon provmakiisionls ofe the i Labor Code,icate yolu of mustufo thwlllhbecome comply Applicant understands and will comply with all non point with such provisions or this permit shi deemed revoked. Source regulations. I cartity that I have read Misapplication antl state that the above Information 19 correct.I agree to comply with all city and county ordinances and state laws relating to building,construction,endTrings to be class" "or better. hereby authorize representatives of this city to enter upon the above -mentions property for Im ��— spectlon purposes. 13 (We)agree to save,Indemnify and keep harmless the City OI Cupertino against liabilities, judgments,costs and expenses which may In any way accrue against said City In oneequanca SIGNATURE OF APPLICANT DATE . 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