99110070E
L -A
PERMIT
v R
APPLICATION FOR CITY OF CUPERTINO NUMBER
IN_ SPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777 -3228 PERMIT EXPIRES, IF WORK IS NOT STARTED '
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR ,
100 DAYS FROM LAST CALLED INSPECTION. '
BUILDING ADDRESS ..
Q"
/ny / 4�
U I 41'
"
Cam! v
RESIDENTIAL COMMERCIAL OTHER
OWNERS,
HAZARDOUS FIRE AREA
I
YES ❑ If yes - I urMeistand that a Class A
NAME�J� I'� �/
1111 assembly is required.
NO ❑ Initial' I.C.B.O. #
_
ADDRESS
EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS -/
'
TO BE REMOVE TO BE RETAINED
D
CONTRACTOR'S
NAME
ADDRESS
TYPE OF ROOF COVERING
CITY & ZIP
EXISTING
BUILT-UP ROOF
PHONE [l d� -
LICENSE
-
NUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 em 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. �
� � �I
WOOD SHINGLES ❑
.License Class 5.�:� Lic. Number T pL�
� .
Data
OTHER (SPECIFY
Q
e OWNER-BUILDER DECLARATION
hereby affirm that am exempt from the Contractor's License Lew for the reason.
PROPOSED '
1�
(Sec. 70315, Business and Any city or county whuhse, ions a
a permit to
-
construct, alter. Improve, to file signed statement any e. Is license Issuance, to the provisions the'
demolish, or rep it any also
applicant for such permit License file aChaptestatement that ns leh Sectio pursuant to the provisions
of ins dole Lew (Chapter Section
U D
- _�BUIL� -UP ROOF .r p
1 Fl 99
NOV 99
ss an sions he (commencing with 7000) of for the 3 of the
Business and Professions Code) or that he is exempt therefrom and the beefs for the slanged
ALT SHIN E$
exemption, Any violation of Seaton 7031.5 by any applicant for a permit subjects the applicant to
f t more
e civil penalty of net more than five hundred tloilere ($500).):
❑I, as owner of the property, or my employees with wages as their sole compensation, will do
the
SHAKES By ❑
work, and the structure Is not intended or offered for sale (Sec. 7044, Business and Profee•
alone Code: The Contractor's License Law does not apply to an owner of property who builds or
improves thereon, does himself
D LES ❑
and who such work 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
OT a�
not build or Improve for purpose of sate.).
CiY ❑
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sac. 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.
I am exempt under Sec. , B C. for this reason
E) B P.
PROVIDE MFGR.INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
ALUATION
ERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
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❑ I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation,
as p rovitletl for by Section 3700 of the Labor Cotle, for the performance of the work for which this
ing
per mlt is leaned.
1 have
)BUtI
to
❑ and will maintain Worker's Compensation Insurance, as required by Section 3700 of
mic
the rf the wo kfor
„the Leber Cotle, for the performance of the work for which thle permit le lasuetl. My Worker'6
/O/ �d
/.
Compens[gy�o Innsurancecarrier antl /Pq /Ilc /9um�be /r era:
aY/- z.+- z-M1-A�
carrier �y'LM t4ir ILyi'�/i7 T�l'i+(St 001cy No. 7
PERMI UTHORIZATION
'DATE
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 lees.)
-I
certify that In the performance of the work for which this'permit Is Issued, I shall not employ
- -
All roofs shall be inspected prior to any rooting material being
any person In any manner so as to become subject to the Workers' Compensation Laws of Cali.
fornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, l agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It. after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
.Applicant Understands and will Comply with all non point
with such provisions or this permit shaKbs deemed revoked.
Source regulations. '
I certify that l 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
All roof r'ngs 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 Gave, indemnity and keep harmless the Clry of Cupertino a ainst liabilities,
i ei
J3jutlgmente, costs and expenses which may In any way accrue against said City in consequence
is grammg of Ims permu.
-II!
ATURE OF PL CA 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