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R 6282 (2) PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R— 6282 . REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408)777-3228 'PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 190 DAYS OF PERMIT ISSUANCE OR ,• 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS & `---n S, Gnz RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA YES ❑ If yes—I understand that a Class A NAMEC_ I J C ✓ NO ❑ roof assembly is acquired. Inigal I.C.B.O.N ADDRESS u Z- I EXISTING ROOF COVERING PHONE �J NUMBER OF EXISTING COVERINGS I CONTRACT R'S r p TO BE REMOVED TO BE RETAINED NAME ADDRESS1 S'z l �� ,J� TYPE OF ROOF COVERING CITY aZIP 1 L/ �J EXISTING PHONE / /N� , /tel 9 z BUILT-UP ROOF ❑ LICENSE NUMBER (.�5 YASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm that 1 am licensed under provisions of Chapter B(commencing with Section. WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and effLien / ` ,-IF 2 WOOD SHINGLES License Claes `� Lle.Number•���J `J� Date_ ) I '- -`)Y Contractor J-1Q••ts"� 1I_K 12Y'L OTHER(SPECIFY) l? 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 BUILT-UP ROOF ❑ applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's License Lew(Chapter 9(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 SHINGLE$ 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).): E]1,as owner of the property,or my employees with sieges as their sole compensation,will do WOOD SHAKES ❑ the work,and the structure Is not Intended or off' 7044,Business and Profea- sionsCode:TheContractors g% er of pmperry who bullds or WOOD SHINGLES ❑ Improves thereon,and�plyddee c work mmsell or through Rfa n employees,provltled that such improvements ere of intentlotl or offered for sale.If,howev the building or Improvement ni Is said within one yearn completion,the ownerA e t urden of proving that he ad OTHER(SPECIFY) ❑ not build or Improve for u e of este.).❑I,as owneronhep • yepxplyayh f ed contractors to construct the project(Sec.7044n s oC !rr tors License Law does not PROVIDE I.C.B.O.REPORT NO. apply to en owner of propbry ho ds or ImprN contracts for such projeaswith econlrectogs)Ilcen (Ip reuent tothe Con 1'. PROVIDE MFGR.INSTALLATION SPECS. ❑ em exempt under ,B&P.C.for this reason OwnerDate APPLICATION DATE VALUATION PERMIT FEE R 'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: �� Q 1 have and will maintain a Certificate of Consent to sal4lnsure for Warkeis Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 2-5-00 Seismic _(_ the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's y^ Compensation Insurance carrier and Policy number are: Total �J Carrier S tag '� Policy No. )12-"643 -g 7 PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.O (This section need not be completed If the permit Is for one hundred dollars($100)or leas.) I certify that in the pedormance of the work for which this permit Is issued.I shall not employ any pennon in any manner ao as to become subject to the Workers'Compensation Laws of Cali All roofs shall be Inspected 13rior to any roofing material being fornia. _ installed. If.a roof is installed without first obtaining an Date Applicant _ .L�-�n� inspection,I agree to remove all new materials for inspection. , NOTICE TO APPLICANT: 11,shot 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 shall be deemed revoked. source 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 slate laws relating to building construction,and All roof coverings to be class-6 or better. hereby authorize representatives of INS city to enter upon the above-mentioned property for In. � apatite)purposes. � G �l9 <:;A _ (We)agree to.aeve,intlemnlly antl keep harmless the City of Cupertino against liebllltlee; judgments,costs and expenses which may In any way accrue egelnal celtl City In consequence • of the granting of this permit. SIGNATURE 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 ,.