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R 5749 PERMIT - ' NUMBER R- 5749 APPLICATION FOR CITY OF CUPERTINO REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408)777-3228 PERMIT EXPIRES IF WORK IS NOT WITHIN 180 DAYS OF PERMIT ISSUANCEANCE OR OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS RESIDENTIAL----AC—COMMERCIAL OTHER OWNER'S ��+s�� _ HAZARDOUS FIRE AREA NAME .9r7` ^ �� �� VES ❑ hoof assemblysnocUnderstand Ued.at a DlaSSA ial— ADDRESS 1/23 €G'i/ d'- -e-�.tL� No EXISTING IRnOOF COVERINGe.o.a PHONE T 6 NUMBER OF EXISTING COVERINGS CONTRACTOR'S NAME �Y A�� � �� Q 4D I ,#S, �� - TO BE REMOVED TO BE RETAINED 4YP ADDRESS pZ ZE OF ROOF COVERING cl.TVBZIP EXISTING PHONE BUILT-UP ROOFLICENSE ❑ NUMBER 3 O .3 ASPHALT SHINGLES ❑ 161, LICENSED CONTRACTORS DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is In full force and et. License r� ;>3 �� '�/ WOOD SHINGLES ElLleenae Cleea Lid.Number J Date 3 6 —TR Contractor OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED 1 hereby affirm that I am exempt from the Contractor's License Law for the fallowing reason. IS 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 Law(Chapter B(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 SHINGLES exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more then five hundred dollars($500).1; , []I,as owner of the property,or my employees with wages as their sole compensation,will do _ WOOD SHAKES ❑ the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Profes. sions Code: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 Bold 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,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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. C]I em exempt under Sec. ,B 8 P.C.for this reason - owner Date WORKER'S COMPENSATION DECLARATION APPLICATIO 'A' VALUATION PERMIT FEE I hereby aalrm under penalty of perjury one of the following declarallon: r' ❑1 have and will maintain 37 a of the of Consent to self-Insure for Worker's Compensation,which this dv'q 3 r� Building pe mitprovidedis for by Section 3700 of the Labor Code,for lM1e performance of the work for which this �/"', g permit isve and NN elSm ❑I have and will the performance Worker's Compensation the wa%for Insurance,as repulsedsu d,My 3700 of C(TY Ur cur -the Labor Code,for the pedormand of the work for which this permit Is Isauatl.My Workers Cry Compensation Insurance carrier and Policy number are: Total Sill Carrier Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE EXEMPTION FROM WORKERS' V COMPENSATION INSURANCE N.C. (This section need not be completed If the permit Is for one hundred dollars($100)or less.) 1 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 Can- All roofs shall be inspected prior to any rooting material being forma. installed. If a roof is installed without first obtaining an Data Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,eller making this Certificate of Exemption,you should become Applicant understands and will Comply with all non oint subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP p y p with such provisions or this permit shafte deemed revoked. Source regulations. I certify that I have read this application and stale that the above Information iscorrect.l agree to comply with all city and county ordinances and state laws relating to building construction,antl All r overings to be class"C" 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,costa one expenses which may In any way accrue against said City In consequence of the gmming 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 '