99110077 ' SGS
PERMIT,
APPLICATION FOR CITY OF CUPERTINO NUMBE
_ REROOF PERMIT - INSPECTION DIVISION - PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
_ WITHIN 180 DAYS OF PERMIT ISSUANCE OR
,180 DAYS FROM LAST CALLED INSPECTION. .
BUILDING ADDRESS - -
-aaam,
RESIDENTIAL�COMMERCIAL• OTHER•
OWNER'S HAZARDOUS FIRE AREA
NAME - YES ❑ If yes—I understand that a Class A -
., . . roof assembly is required.
•NO '❑ 'Imbal ' I.C.B.O.R
ADDRESS ' �YY��- EXISTING ROOF COVERING
'PHONE - T� --58' ZZ NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
NAME �
TO BE REMOVED / TO BE RETAINED
_- jy �;�p
ADDRESS`bG� U ` TYPE OFR FIGOVERING
--�--
clry a zlr> � �. p
EXISTING (�I
PHONE -"BUILT-UP ROOF DC o(�(� ( I
'LICENSE /' ►/ 1 NISI 15 19N
NUMBER- Io S l ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION r -
I0)ofhereby affirm that Pam licensed under provisions ode, ,ter 9(commencing with Section' 'WOOD SHAKES BY__
]000)of Division 3 of the Business and Professions code, ntl��y Ij(:eW n farce and
-
' effect. n - � .`7J 7< T�i � , -
' .02 - WOOD SHINGLES -
,License Class Lie.Number' '
Date GC - Contractor OTHER(SPECIFY) '
OWNER-BUILDER DECLAR IDN PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason:
(Seer 7031.5,Business and Professions Code: Any city or county which requires a permit to -
- construct altar,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 9(commencing with Section 7000)of Division 3 of the ((��ww
Business and Professions Code)or that he is exempt therefrom and the basis for the applicant
ttl ASPHALT SHI S ,,I V
exemption.Any violation of Section 7031.5 by any s($5 ant for a permit subjects the applicant to
a civil penalty of nct more than five hundred dollars($500).): � � - -
' ]I,as owner of the property,or my employe as with wages as their sole compensation,will do ,WQQD SHA
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 S - O
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 OTHER 3PECI -
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 Contractors License Law does not PROVIDE.LC.B.O.REP�Q;
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]I am exempt under Sec. B 8 P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
Owner Data
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 self-insure for Workers Compensation
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �s �/D /O
permit issuetl. L
haisve and will maintain Workers Compensation Insurance,as required by Section 3700 of Seismic
t Labor Code,for the performance of the work for which this permit is issued.My Worker's
ompensetion�lnsura}ceLerrier and Policy number are: Total
Carrier �� ,(6Z�k�� PolicyNo�83"Q9
CERTIFICATE OF EXEMPTION FROM WORKERS' �(y PERMIT AUTHORIZATION DATE
- -
COMPENSATION NC.I] ,
(This section need not be completed if the permit is for one hundred dollars($100)or less.) -
I certify that in the performance of the work for which this permit is issued,I shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali= All roofs shall be.inS ected prior to an roofing material bein
forms. - P P Y 9 g
installed. If a roof is installed'without first obtaining an
Date u CS Applicant inspection,I agree to remove all new materials for inspection:
NOTICE TO APPLICANT: It,after making this Certific a of Exemption,you should become -
Subject to the Workers'Compensation provisions of the Labor Coda,you must forthwith comply Applicant understands and will comply with all non point '
with such provisions or this permit shall be deemed revoked. - SOUfCe regulations. -
Icertify that lhave read this application and stale 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"&r better.
hereby authorize representativesmf this city to enter upon the above-mentioned property for in. -
spection purposes. - the-City O
(We)agree s save,pensesiw antl keep harmlessccrua against
Cupertino against liabilities, -
ofthe guts,costs and expenses which may in any way accrue against aeitl City in consequence
of
granting of this permit. SIUNAI UR6'OF APPLICANT �D�ATE '
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 - '