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R 5956 (2) PERMIT R_ 5956__ APPLICATION FOR CITY OF CUPERTINO NUMBER REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION ��n/ (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED (� WITHIN 100 DAYS OF PERMIT ISSUANCE OR 160 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS 1 / G/I / 6C RESIDENTIAL COMMERCIAL OTHER 0 iNE C HAZARDOUS FIRE AREA NAM IIJ�hS l)T /✓A, ,,Jin' ,l 3S YES ❑ rmfasembly is srequiretand BClassA 1 root assembly is required. S' f ❑ IN LGB.0.8 ADDRESS /i2 S EXISTING ROOF COVERING PHONE — 9(p Qb NUMBER OF EXISTING COVERINGS ' CONTRACT/C�H�S ////�� NAM__Fes(/S S O- �`J 9 , TO BE REMOVED / TO BE RETAINED ADDRESSn s oS TYPE OF ROOF COVERING CITV8ZIP - •�f6X // /l?/ XE ISTING LICENSE PHONE 4OYG//� ^�("��/ Z BUILT-UP ROOF El NUMBER ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Sectio WOOD SHAKES 7000)of Dlvlelon 3 of the Business and Professions Cod entl my license le In lull force tl anent. WOOD SHINGLES ❑ License Class Lic.Number ✓ L Date Contractor ER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractor's License Law for the following reason. !�I�.$ (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to P' construct,alter,improve,demolish,or repair any structure,prior to Its Issuance,also requires theBUILT-UP ROQF A ® •� ❑ applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions �pnn of the Contractor'$License Lew(Chapter 9lcommencin9 with Section 700D)of DlvleIon 3 of the �®�S7 ❑ • Bu$Inaea and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SH exemption.Any violation of Section 7031.5 by any applicant far a permit subjects the applicant to e civil penalty of not more then five hundred employees dollars with wag.); SH ❑Irks and er the structure I not i my tended oyeeeredfwegee(See.7 44,ole compensation,will s. WOOD SHAKES the work,and Iha structure la not intended or offered for sale(Sec.7044,Business entl Proles- ` slons Coda:The Contractor's License Law 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 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) E3not 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 Contractoes License Law 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. U C]I am exempt under Sec. ,B&P.C.for this reason OwnerDate WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: , ❑1 have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit leve and. p Seismic ❑1 have and will the performance Worker's Compensation the work for Insurance,as required by Section 3700-s — 1� -98$ /� Coor oda,for the performance of the work for which this permit is issued.My Worker's Total Iy 8 Compen on lnaurenc9 carriers Poll bar e`e: � G Carrier Policy N& 4/ 4400 PERMIT AUTHORIZATION DATE CERTI ICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.❑ �-t�• ' (This section need not be completed if the permit Is for one hundred callers(5100)or lass.) ` pe A O 0-1 _ n I certify that In the performance of the work for which this permit Is Issued,I shell not employ v O any person In any manner so as to became subject to the Workers'Compenmtlon Laws of Cell. All roofs shall be inspected prior to any roofing material being tornia. - - 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 subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP ply with all non point with such provisions or this permit shall be deemed revoked, source regulations. - I certify that l have read this application and slate that the above Information is correct.l agree to comply with all city and county ordinances and state laws relating to building construction,and All roof cove yf g to be class"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In- spection purposes. (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, 7-14-7 of ttge entat costsgrant nB of tand his paPmlisas which may In any way accrue against ultl City In consequence SIGNA E OF APPL 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