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R- 4 5 21
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
I I
RESIDENTIAL !!f!!COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
6
YES ❑If yes - I understand that a Class A
NAME _ rA 2_
1117assembly is required.
❑ Initial I.C.B.O. #
Ave-NO
� ^
1 Av
EXISTING ROOF COVERING
ADDRESS-1.0� n f l fm
PHONE -
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
CONTRACT9�'S ""
NAME C'on fCld / lli�I ACA
(L ,e_- p . ^(
ADDRESS 33-2 QhP q 5112-
TYPE OF ROOF COVERING
TIV �lG 1D Sp
n� n
CITYB ZIP(,f
EXISTING
,�
(409) 7-91y-1101.5
PHONE
BUILT-UP ROOF ❑
LICENSE
NUMBERZip
ASPHALT SHINGLES ❑
WOOD
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under of Chapter B (commencing Section
provisions with
700 0)of Division 3 of the Business and Professions Code, and my license Is In full force and
$HAKES
effect.
�+
License Class I Llc. Number 211 w� Z l Q
S INGLES P A[I)D
Date (0I f I gix,, (� � XContractor � ` /1A -11W w
iL
2 TH CIF a -r OCT ❑ 9���
OWNER BUILDER DECLARATION
!/ F� 1
1 hereby a#Irm that I em exempt from the Contractor's License Law for the following reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to
CITY Uf
construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the
VUH I IN
BUILT-UP ROOF O
appllcant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law (Chapter g (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 than five hundred dollars ($500).):
I]1, 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 (Seo. 7044, Business and Profes.
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 ❑
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) El
bulb or Improve for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The Contractors 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 Lew.
❑ 1 am exempt under Sec. ,8 6 P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Data
APPLICATION DATE
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 self -insure for Workers Compensation,
Building./
g
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
�/s
permit is issued.
�1/
have one will Workers Insurance, as required by 37G0rs
Seismic
the pelrf
-ftthe
f the work
the Labor Code, for the performance of the work for which this permit Is Issued. My Workers
for d. My
Insurance carrier entl Policy number are:
Total
Carrier Policy No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need not be completed it the permit Is for one hundred dollars ($100) or leas.)
I certify that In the performance of the work for which this permit Is issued, I $hell not employ
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 Calf
fornia.
installed. If a roof is Installed without first obtaining an
Dale Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE ecome
subject to the OWorkers' Compeinsation provi, after sions ofethe ilLabor Code, cate of Exemption,
ou mustufo thwlltlhbcomply
Applicant understands and will comply with all non point
with such provisions or this permit shalQbe deemed revoked.
Source regulations.
I certify that I have read this application and state that the above Information Is orrect.I agree
to comply with all city and county ordinances and mate laws relating to buhding construction, and
All roof covering o be class "C" or better.
hereby authorize representatives of this city to enter upon the above-msnoioned property for In.
spa tion(We) agree toe.
(We) agree save, and keep harmless Ice Clry liabilities,
/D_ x -
s expanses was ai st mid Ci y Inagainstcon
ofthe gran costs and expenses which they In any way accrue against said Clry In consequence
of the granting of this permit.
NATURE 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 A PROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
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