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R 5052 (2) PERMIT q_ 5052 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 100 DAYS OF PERMIT ISSUANCE OR • - 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS v2 RESIDENTIAL COMMERCIAL OTHER OWNERS �/ /� HAZARDOUS FIRE AREA ��j��/[ /J7�� / � VES ❑ Ilyes—Imbly is required. ClassA NAME/� a/07 ll r /✓// ( roof assembly is required. �j�// � �D v NO Imhel LC.B.O.k ADDRESS ` (/v ,/((/ EXISTING ROOF COVERING fir PHONE O NUMBER OF EXISTING COVERINGS CONTRACTOR'S /f TO BE REMOVED_ TO BE RETAINED NAME V ADDRESSr/J F ROOF COVERING CITYBZIP /J n EXISTING PHONE v �v BUILT-UP ROOF ❑ LICENSE NUMBER ! ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and affect. WOOD SHINGLES License Claes Lid.Number - Date Convector OTHER(SPECIFY) OWNER-BUILDER DECLARATION PROPOSED I hereby aklrm that I am exempt from the Contractor's License Law for the following reason. (Sec.7031.5,Business and Profession;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 ❑ , applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions BUILT-UP ROOF r of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 101 the �gq5/ s A • Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINVLI /1% exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to fY a civil penalty of not more then five hundred dollars($500).): 19 (� ❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES Ut- 900 the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and PrDfes• LUr• slons Code:The Contractor's License Law does not apply to an owner o1 property who builds or WOOD SHINGLES r r f Improves thereon,and who tloes such work himself or through his own employees.provided that qyV❑ such Improvements are not Intended or offered for sale.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,em exclusively contraolng with licensed contractors to construct the project(Sec.7044,Business and Profession,Code:lPhe 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(;)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑I am exempt under Sec. ,B 5 P.C.for this reason Owner Date APPLICATION DATE VALUATI PERMIT FEE WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declaration: ❑1 have and will maintain a Certificate of Consent to selbinsure for Worker's Compensation, Building permit Is Is for bySection 3700 of the Labor Code,for the pedormance of the work for which this /��Iff rA permit lave and Jf�/i/// U Seismic ❑ have and will the performance Worker's Compensation Insurance,as required su Section 3700's the Labor Code,for the pedormance of the work for which this permit le Issued.My Worker's Compensation Insurance denier and Palley number are: ( Total Carrier Policy No. PERMIT AUTH RIZATIO DAIE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.CbD (This section need not be completed If the permit Is for one hundred dollars($100)or lees.) 1 cenity that In the performance of the work for whl le permit Is Iseysd-, shell not employ any person In any manner so as to become subject ha orkere c rrlpensandn Laws of calk All roofs shall I s ectedprlor to any roofing material being forma. of installed. If a roof is installed without first obtaining an Date Applleent inspection,I agree to remove all new materials for inspection. OTI subject toEthe Workers'Compensation provisionANT. 11,after is ofetheflLat or Code.you must forthwou lithbecome comply Applicant understands and will comply with all non point with such provisions or this permit shall be deemed revoked. source r ulations. 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 state laws relating to building construction,and ZG c0 i In be class„C„Or better. hereby authorize representatives of this city to enter upon the above-mentioned properly for In. eDectlon purposes. ! •/G%/F///// (We)agree to save, Indemnify and keep harmless the City of Cupertino against liabilities, judomenta,coat.antl expanses which may In any way accrue against said City n consequence • of the granting of this permit, URE,0F9PPLICANT 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