00040004 o60,g000c( J
• PERMIT ,
APPLICATION FOR CITY of cuPERTIrio NUMBS
REROOF PERMIT , INSPECTION DIVISION. PERMIT EXPIRATION ,.
(4O6)]]]-3ZZ6 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS.
• RESIDENTIAL COMMERCIAL OTHER
,. OWNER'S - HAZARDOUS FIRE AREA
/gyp � ,y 'YES El If yes—I understand that a Class A
NAME' r(„' `,`4 _ �/.Qi.P // roof assembly is required.
,// NO " ❑ Initial I.C.B.O.
9i N
ADDRESS � /5Y2, AW C//C vL LQ ,EXISTING ROOF COVERING
PHONENUMBER OF EXISTING COVERINGS `
CONTRACTOR' G.
S ///7 _ 1
ze -//� TO BE REMOVED TO BE RETAINED
NAME �G \\\ C-
ADDRESS � TYPE OF ROOF COVERING
CITY&ZIP �r~ / '{/
/��y � - _ -
7-G�? ✓S>P .t ,it EXISTING
PHONE— y[e¢��-rj--moi BUILT-UP ROOF .. ❑-
LICENSE
..
NUMBER CO ASPHALT SHINGLES El '
LICENSED CONTRACTORS DECLARATION '
hereby affirm that 1 em Business
licensed under provisions of Chapter 9(commencing with Section _ WOOD SHAKES '
1000)of Division 3 of the Business antl Professions Code,and my license is In full farce and
.
enact.
'License Class�L= Lic.Number WOOD SHINGLES
Data 2 Coenmctor OTHER (SPECIFY) ��❑ ��
- . OWNER-BUILDER DECLARATIIJ�J— S_ PROPOSED '
I hereby affirm that ram 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
construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT UP ROOF El `
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
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 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,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 Cade: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 sold 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.). O_ (SPECIFY) ❑
L]1.as owner of the property,am exclusively contracting with licensed contractors to construct - -
the project(See.7o44,'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 buiIds or improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. . .PROVIDE MFGR.INSTALLATION SPECS.`
❑1 am exempt under Sec. ,B&P,C.for this reason
Owner Date .
WORKER•SCOMPENSATION DECLARATION - APPLICATION DATE ' VALUATION I PERMITFEE
I hereby affirm under penalty of perjury one of the following declaration:
El I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation,` BUlldm
as provitled for by Section 3700 of the Labor Code,for the performance of the work for which this g
Parm d-isiesued. L/
[�Q have and will maintain Workers Compensation Insurance;as required by Section 3700 of _ Seismic
the4ebor Code,for the performance of the work for which this permit is issued.My Worker's
r
Compensation
Insurance carrierand Polic umber are ,Tota
Carder ie R��P �x(y1 _ Policy N..'_ydD-i,� ' •PERMIT AUTHORIZATION DATE -
CERTIFICATE OF EXEMPTION FROM WOR ERS' _
COMPENSATION INSURANCE N.C. -
(This section need not be completed if the Permit is for one hundred dollars($100)or less:) 3j(j .—2S .— 0 /57 -
,,, I certify that in the performance of the work for which this permit is issued,I shall not employ J '
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali- ' All roofs shall be- inspected prior to an roofing material being
installed. If a roof is installed without first obtaining an
Data Applicantinspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,yousrthhould become Applicant understands and will with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP comply p y
with such provisions or this permit shall be deemed revoked. • ' source regulations.
I certify that I 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 coverings to be Class"C" befter.
hereby authorize representatives of this city to enter upon the abovementionetl property for in-.
sPe) purposes.
(W
(We)agree s save,pensesiwhich keep harmless the City of Cupertino against liabilities, '
judgments,costs and expenses which may in any way accrue against saitl City in consequence ATS--
of the greening of this permit. -. SIGNATURE P LICA 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION '
Y OFFICE COPY - ,