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R 5763 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5763 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (GOB)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 100 DAYS OF PERMIT ISSUANCE OR 100 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS RESIDENTIAL :�L COMMERCIAL OTHER OWN ER's ?�P Srn Q r.,5• HAZARDOUS FIRE AREA YES ❑ If yes—I understand that a Class A - NAME roof assembly is required. 51-0,A. ++ TT NO Initial I.C.B.O.N ADDRESS J•J •Orn. I F COYERING 4s/z 3 PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S NAME ��� '" TO BE REMOVED TO BE RETAINED ADDRESS TYPE OF ROOF COVERING CITY&ZIP / 1 EXISTING PHONE `� 22y^585 BUILT-UP ROOF ❑ [ J LICENSE 1-1 NUMBER O 1 sc/V ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION - Q I hereby aHI m that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES 137000)of olvisi n 3 of the Business and Professions Code,and my license Is In full force and effect. WOOD SHINGLES 11License Class Lic.Number ' ontractor OTHER(SPECIFY) X @dew.i� S Date DBUILDE OWNER the oER DECLARATION PROPOSED hereby 5,,IrmBu that I em exempt from the e: Any License Lew for the lona a reason. (Sec.7031alter, ,Improve and Profedemolish, or rep Code: Any city or county which requires requires permit to construct.alter,improve,tofile eigneepebenyetructure,prior tolls lesrsuai also theprovisions rovithe BUILT-UP ROOF ❑ applicant for etch permit a Ills deigned r 9(commencing that g it licensed 7000)of the pro of the of me ss and Prof License Lew(Chapter 9(commencing with omcand th e0)of Donlon athe �t ex Business and violation of Coda)or that he Is exempt therefrom and the baste tor.the alleged atto ASPHALT SHINGLES exemption.Any violation of than Section 7031.5 by any applicant for a permit Subjects the applicant to e civil penalty of not more termor bundredy employees do yeesra(h wag): WOOD SHAKES ❑I,as owner of the property,or to employees with wages as their Bola compensation,will s. ❑ the work,and the structure Is not Intended or s nota for eels now owner of Badness and ulkla or Code:The Contractors License such Law domenotapply toenowner ofproperty whoidedtor WOOD SHINGLES ❑ Improves thereon,and who does such work redforhimself or through ev own employees,Improvement provided that such Improvements ne ye are not Intended the offered for edea.ill however,the en of pr or Improvement Issoldbuild thinor prove for purpose sthe owner•bullder will have the burden of proving that he tlltl OTHER SPECIFY not build or Improve for purpose of sale,). (SPECIFY) ❑1,asownerof the property,am exclusively contracting with licensed contractors to construct the project(Seo.7044,Business and Prole iftr s Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NOS 39v6 apply to an owner of property who build$or Improves thereon,and who contracts for such projects � �� Y exempt with acontlicensed pursuant to the Contractor's License Lew. P�OVIDE MFGR. INSTALLATION SPEC$. ❑I em exemptt antler Sac. ,B 8 P.C.for this reason O Owner Date LICA 1 DATE VALUATION PERMIT FEE WORKERS COMPENSATION DEC declaration:I hereby affirm antler penalty of perjury one of the following oeelaratlon: ❑1 have antl will maintain a Certificate of Consent to aelldnsure for Worker's Compensation, G• �(y BuildIn as provided for by Section 3700 of the Labor Code,for the performance of the work for which this L' " .�i7A. ©b g permit Is Issued,vandGF�•7 V/ ^� Seismic ❑I have and will maintain Workers Compensation Insurance,as required by Section 3700's _Ina Labor Code,for the performance of the work for which this permit le leeuatl.My Worker's Compensation Insurance carrier and Polity number are: ��(� Total Carrier Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.O� (This section need not be completed If the permit Is for one hundred dollars($700)or lase.) I cenlly that in the performance of the work for which this permit Is Issued,I shall not employ any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being fornia. installed. If a roof is installed without first obtaining an Data Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: ll,after 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 comply with all non point with such provisions or this permit shsllibe,deemed revoked, sOUfCB regulations. I certify 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 stele 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-mentioned property for In. ep(We) purposes. / n 14— judgments, (We)agrees andsave,Indemnexpenses and keep harmless cc Clry ai Cupertino y Inagainstcon liabilities,ence /lfL �ftll�— / lutlhe gaming costs and expenses watch may In any way accrue against said Clry In consequence of the gmmtng of this permit. NATURE 0 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