99080051i
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-/ 5 PERMIT ",
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APPLICATION'FOR : CITY'OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION' - PERMIT EXPIRATION .
`» (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
- - _ WITHIN 180 DAYS OF PERMIT ISSUANCE OR .
100 DAYS FROM LAST CALLED INSPECTION
'BUILDING
/ADDRESS
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
'
YES . ❑ If yes - I understand that a Class A
NAME
roof assembly is required. '
NO ❑ Initial I.C.B.O. #_
ADDRESS
.EXISTINGROOFCCCOLVERING
NUMBER OF EXISTING COVERINGS — `
' , N D
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PHONE (Q —� D
CONTRAC
ORS
NAME
e_
I
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ITL�J C
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TO BE REMO VED TO.BE RETAINED
ADDRESS 1
p-
- TYPE OF ROOF COVERING
CITY & ZIP oC
e
-
EXI ING
P7
PHONE `7�7�7
BUILT °UP ROOF E-1
,`.-
LICENSE
NUMBER`(J�
ASPHALT SHINGLES E]
' 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
- ..
ease. ^. 3 (
WOOD SHINGLES .
License Class C Lic. Numbs
PO —%�
OTHER (SPECIF
Date _� Contract `
OWNER -BUILD LARATI
hereby affirm that am exempt from the Contractors Licen Law far the following reason.
'PROPOSED
. (Sec. 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
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
BUILT-UP ROO ❑,
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and the basis for the applicant to
exemption.lty of violation more Section hundred d do a applicant for a permit subjects the applicant to
. e civil penally of not more than five dollars ($$OOL):
ASPHALT SHINGLES
of
y employees
❑ I, as owner of the property, or my employees with wages as the!r sole compensation, wi 11 do
the work, no the structure is not intended or offered for sale (Sec. 7044, Business and Prates.
WOOD SHAKES
Ll
sions Code: The Contractor's License Law does not apply to an owner of property who builds or
improves thereon, and who does such work himself or through his own employees, provided that
%
WOOD SHINGLES Vl ❑
such improvements are not intended or offered for sale. If, however, the building or improvement
- -
issoldwithinoneyearofcompletion ,the owner - builder will havens burden of proving that he did
not build or improve for purpose of sale.). '
OTHER (SPECIFY) .
❑l, 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 contractors) licensed pursuant to the Contractor's License Law.
• ❑ am exempt under Sec. _ ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION ',
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to salt- Insure for Worker's Compensation,
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as provided for by Section 3700 of the Labor Code, for the of the work for this
(p
Building / (��
I-A - I
performance which
permit is Issued.
I have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
th L bor Cade, for the performance of the work for this is
A
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SeismI
which permit issued. My Workers
Compensation Insur nce carrier and P icy number are:.
-
] Z—. rs.�
Total '+/':�)'/fdX/�]
carrier —s y V1 Policy NO�� –�' L � J I
'
PERMIT AUTHORIZATION
DA
' CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE N.C.0
(This section need not be completed If the permit is for one hundred dollars ($100) or lass.)
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"I certify that in the Performance of the work for which this permit is issued, I shall not employ I
All roofs shall be inspected prior to any roofing material being
any person in any manner so as to become subject to the Workers' Compensation Laws of Cali- ..
forma.
..
installed. If a roof is installed Without first obtaining.an
pate Applicant '' -'
inspection, I agree to remove all new materials for inspection.
NOTICE a APPLICANT: If, after making this Certificate of Exemption, you should beco
subject to the Workers' Compensation provisions the Labor Code, you must forthwith comply
, Applicant understands and will comply with all non point.
pp
with such provisions this permit shall d
deemed revoked. r,
SOUfOe regulations. _
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I certify that l have read this application and state that the above information is cormcLlagree
to comply with all city and county ordinances and state laws relating to building construction, antl —
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A OJcoveri St0 e C SS �kJOr better.
hereby aphorise representatives of this city to enter upon the above - mentioned properly for n- herebon
purposes.
(We) agree to save, indemnity and keep harmless the City of Cupertino against liabilities,
,
judgments, casts and expenses which may in any way accrue against said City in consequence
S NATU R APP C , N -
DATE
- of the granting of this permit.
PRE - INSPECTION:' -
.PLYWOOD: - -
IN- PROGRESS:
INSP. -' - DATE
INSP.- DATE
INSP.' DATE
TEAR OFF INSPECTION: -
4
BATTENS: _ I -
"
FINAL: - -
INSP. DATE
INSP. DATE
INSP. DATE
NOTE: 'OSHA APPROVED ACCESS TO'ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE-COPY