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R 5887 CITY OF CUPERTINO NUMBER PERMIT R- 5 H H 7 APPLICATION FOR ' 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 RESIDENTIAL COMMERCIAL - OTHER owNER s HAZARDOUS FIRE AREA NAME Y C9 Vl - YES ClIt yes—I understand that a Class roof assembly is required. NO ❑ Initial I.C.B.O.If ADDRESS S 0.VW'ii EXISTING ROOF COVERING PHONE "' C(. NUMBER OF EXISTING COVERINGS / CONTRyCTOR DD__ //�'��� NAME CA L..fJo—&3 Q.r TO BE REMOVED TO BE RETAINED DD&Z P Q TYPE OF ROOF COVERING CITY Zc 5 EXISTING PHONE Jt�!—/,2 .3s BUILT-UP ROOF ❑ NUMBER ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES `+C4XI 7000)of Division 3 of the Business and Professions Code,and my license Is In lull force and effect. WOOD SHINGLES ❑ License CIe96 LIC.Number { DateOTHER(SPECIFY) Contractor OWNER-BUILDER DECLARATION PROPOSED hereby affirm Bu Business em exempt from the e: Any or roue Law for the following reason. (Sec.7031.5,Buelneee end Professions Code: Any city or county whish requires a permit to , construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑ applicant(or 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 Sectlon 7000)of Division 3 of the Business and Professions Cotle)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 e civil penalty of not more than five hundred dollars($500).): (:j 1,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. sions Code:The Contractor's License Lew does 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 gale.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.).' ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.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 contrectons)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS. C]I am exempt under Sec. ,B 8 P.C.for this reason Owner oats WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: ♦♦♦♦ g��s,�� ❑1 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, Building 1 as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this permit Is leeuetl. SBISm�C E]I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Ll t4he Labor Code,for the performance of the work for which this permit Is Issued.My Workers B /A rwlr.� CompeNtiiImo'onn lnsureince carrier a Il num r ale: _ IDA `© Total Carrlled n (mki TI'O Qtlloollcy N T AUTHORIZATION DATE � CERTIFICATE OF EXEMPTION FROM WORKERS' Q�y 1. COMPENSATION INSURANCE N.C.0 �J• _ ^ (This section need not be completed If the permit is for one hundred dollars III or less.) Lam. 7 I certify that In the performance of the work for which this permit Is leeuetl,I shell not employ err' any person In arty manner so ee to became subject to the Workers'componsauan Laws of Call. All roofs sh I be inspected prior to any roofing material being fomla, 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: It,atter making this Certificate of Exemption,you should become A Ilcant understands and will comply with all non point subject h the Workers'Compensation slanted deemed of the kebor Code,you must forthwith comply PP p y with such Provisionsr ad permitgcation tlee ate revoked. SOUfCe regulations. sappy melIhave reedounty this ordinances statethatlaws relating Information is correct. spree to hereby ty with as cityrep and county of this ccs to entetu o n the trove- entii n construction,f and All roof coverings to be class"C"Or better. hereby authorize representatives of this city to anter upon the above-manllonatl property for In. spectlon purposes. (We)agree to save,Indemnify and keep harmless me City of Cupertino aggainst liabilities, A_Lt>A d y—In- rU judgments,costa and expenses which may in any way accrue against said City In consequence • of the granting of this permit, SIUNA1 URE OF 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 ' OFFICE COPY "