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R-5177 (2) PERMIT R_ 5177 APPLICATION FOR CITY OF CUPERTINO NUMBER 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 106-3 Z ; UIQ RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA / /J� -�/)'� _ ' / YES ❑ If yes–I understand that a Class A NAME 1/Q ,` n / �� �-�./ roof assembly is required. ,,��11 NO Initial I.C.B.O.N ADDRESS— -111 �S 2— Z3 vtook La a �/ EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S TO BE REMOVED TO BE RETAINED NAME ADDRESS TYPE OF ROOF COVERING CITY&ZIP EXISTING • PHONE BUILT-UP ROOF ❑ CENSE NUMBER y SPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION ` I hereby affirm that I em licensed under provisions of Chapter B(comma Ing with Sect faS OD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is lull force an affect, WO D SHINGLES ❑ License Cless Lic.Number Date Contractor OTH R(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROP D I hereby affirm that I am exempt from the Contractor's License Lew 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,priorto 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 Law(Chapter a(commencing with Section 7000)of Division 3 0l 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 wl -rally of not more than five hundred dollars($500).1: WOOD SHAKES s owner of the property,or my employees with wages as their sole compensation,will do El war ,and the structure is not intended or offered for sale(Sec.7044,Business and Profes- sIons Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ Improves thereon,antl 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-bullder will have the burden of proving that he did OTHER(SPECIFY) ❑ not build or Improve for purpose of sale.). ❑1,as owner of the property,em exclusively contracting with licensed contractors to construct the project(Sac.7044,Business and Professions Code:The Contractor's 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 Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B It P.C.Mr this reason nerDete APPLICATION DATE VALUATION PERMIT FEE WORKER'S C ENSAA ION QA ARATION he by al m under penalty al perjury one of the loll wi tleClaratl0n: �as� ❑In end will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, ,- �; - Building ` L as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Seismic [II have and will maintain Worker's Compensation Insurance,as required by Section 3700 of SEP 2 3 a the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's Compensation Insurance carrier and Policy number are: 1°gg pt�p Total Carrier Policy No. ('f 1l'vr ,P,ERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' .. • COMPENSATION INSURANCE N (This section need not be completed If the permit Is for one hundred dollars($100)00)or less.) � /V�"����}a L/KL� I certify that In the performance of the work for which this permit Is Issued,I shell not employ any person in any manner so as to become subject to the Workers'Compensation Laws of Cali. All roots shall be inspected prior to any roofing material being fornia, 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,alter making this Certificate of Exemption,you should become Applicant understands and will comply with all non subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply p y point with such provisions or this permit shalCbe deemed revoked. source regulations. - t 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 state 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-mentloned property for In- spection purposes. (We)agree to save,Indemnity and keep harmless the City of Cupertlno against liabilities, judgments,costs and expenses which may In any way accrue against said City In consequence • of the granting of this permit. IG E OF APPLICANT TE 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