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R-5518 4 PERMIT APPLICATION FOR CITY OF CUPERTINO NU BER R- 5 518 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 1 B DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS • RESIDENTIAL COMMERCIAL OTHER OWNER'S I HAZARDOUS FIRE AREA YES ❑ If yes—I understand that a Class A NAME roof assembly is required. NO Initial I.C.B.O.N ADDRES EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTO / TO BE REMOVED TO BE RETAINED NAME ADDRESS /1, TYPE OF ROOF COVERING CITY&ZIP30 EXISTING PHONE BUILT-UP ROOFLICENSE NUMBER ASPHALT SHINGLES p� LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑ . 7000)of Dlvlslon 3 of the Business and Professions Code and my license is In full force and q� effect. PAI? of WOOD SHINGLES ❑ p�G '1j Y License C ss Uc.Number O Y� OTHER(SPECIFY) ❑ Ur +rh Date Contractor Gilt OWNER-BUILDER OECLAR ION PROPOSED —^ I hereby affirm that I am exempt from the e: Any city License Lew for the following reason. (Sec.70315.Business and Professions Coda: Any city or county which ce,also requires a permit m �{/v construct,alter,Improve,to file demolish,or repair any structure,prior to Its Issuance,also reproves the BUILT-UP ROOF applicant for such permit to flaw a signed statement that g islicensedSectio pursuant to the provisions of the ss and Contractor's License Law(Chapter 9(commencing with om and 7000)of for the 3 of the . Business and violation of Code)or that he Is exempt therefrom entl the bases for the isallegedtto ASPHALT SHINGLES exemption-Any violation of than five 7031.5 by any applicant for a permit subjects the applicant to acivil penalty e not more man,or by dred employees (h wag): WOOD SHAKES I,as owner of me property,or to ded oyeee with wages as their sole compensation,will do ❑ the work,and the structure is not intended ores not for Sale(Sec.owner at Business and builds o- improCotle:The Contractor's License Lew does not apply to an ownere property who builds or WOOD SHINGLES ❑ Improves thereon,and who doessuchwork ed for or through has own employees,improvement ant is so Improvements are not Intended or Owner-builder for seer.If,however, ur en Of pr or proving netsold bullwithinor proven purpose of sthe ownarbulltlerwill have the burtlen of provingihthe tlld OTHER (SPECIFY) ❑ not build or Improve for purpose of ealeJ. I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractor's 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 contraclor(s)licensed pursuant to the Contractor's License Law. - PROVIDE MFGR. INSTALLATION SPECS. 1 am exempt under Sec. ,B 8 P.C.for this reason Owner Date APPLICATI' WTE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration: ❑1 have and will maintain a Certificate of Consent to seff-Insure for Workers Compensation, AUG 1 &rC Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /�[{/ permit Is Issued. CITY Vi' Seismic ❑I have and will themaintainrt Worker's Compensation which this as permit by d.My Worker700 of's CITY! V CUrkH i i w�f toe Labor Code,for the performance of the work for which this permit la Issued.My Worker's N © r r n� Total C.... al] rl carr dPollc�number aro: ����y ���.7 �.V Carrier PoucyNo. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.] 1 (This section need not be completed If the permit is for one hundred tlollars(5100)or less.) l 1 certify that In the performance of the work for which this permit Is Issued,1.hall not employ any person In any manner so as to became subject to the Workers'Compensation Laws of Cali. All roofs shallbe 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. NOTsubject I.theCE OWorkers'Compensation provisions of offthe Laborr Coda,rtificate of Exemption, ou must fothwlshe dthbecome compl Applicant understands and will comply with all non point with such provisions or this permit shall be deemed revoked. comply source regulations. I certify that 1 have read this application and state that the above Information Is correct agree to comply with all city and county ordinances and State lawn relating to building construction,and Allroof overings 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,Indemnity and keep harmless the City of Cupertino against liabilities, judgments,costs and expenses which may In any way accrue against said City In c ..equence SIGNATURE OF APPLICANT DA of the 9rof this Permit. TE PRE-INSPECTION: ION: 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