00010060 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL—OTHER----4—
OWNERS
OMMERCIAL OTHER_-4_OWNER'S HAZARDOUS FIRE AREA
NAMEIUJaYES ❑ If yea; understand quired. ass A I
'''I ��r/(/�' '�/) /� p /��, NO ❑ Initial I.C.B.O.W
ADDRESS-A ✓ ��/CJ�!ll.I V l 1 I"�� EXISTING R OF OVERING
PHONE 't NUMBER OF EXISTING COVERINGS
CONTRTOR'5 I
V � J� VC(
! z TO BE REMOVED�TO BE RETAINED
NAME ^ VU LIJ.�
ADDRESS r �;� �� l t�A 1 , '� j�a l TYPE OF ROOF COVERING
CITYBZIP ✓ P-v� A (i
EXI IN
PHONE
BUILT-UP ROOF
LICENSE I
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION ���
hereby affirm that am licensed under loss of Chapter 0(commencing with Section WOOD SHAKES
7000)of Division 3 al the Rosiness and Professions Code,and my license Is in full force and
affect. �' WOOD SHINGLES ❑
License C ss Uc.Number
Date Contractor � ;
OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the fallowing reaso .
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve,demolish,or repair any structure,priorto Its issuance,also requires the BUILT-UP ROOF �J
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions ^ l❑
of the Contractors License Law(Chapter B(commencing with Section 7000)of Division 3 of the , 1 �y-•O
Business and Professions Code)or that he is exempt therefrom and the basis for the applicant
ASPHALT SHINGLE
exemption.Any violation of Seaton 7031.5 by any applicant for a permit subjects the applicant to LILOOO
a civil penalty of not more than live hundred dollars($500).): p
❑l,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(Sea 7044,Business and Profes-
alone Cade:The Contractors License Law bees not apply to an owner of property who builds or WOOD SHINGLES
improves thereon,and who dues 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 bund or Improve for purpose of sale.).
I,as owner offal property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Cotle: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 Law. PROVIDE MFGR. INSTALLATION SPECS.
❑I am exempt under Sec. B 6 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE '
I hereby affirm under penalty of perjury one of the following declaration:
❑I haveand rbwill maintain o Certificate of Consent to performs for Worker's Compensation, T, \ )� Building
as provided for by Section 3700 of the Labor Code,for the performance of Wthework for which this ' /�/1'V V
Xparr . UJ
is Issued. / SeISn11C
/q�Uleve antl will maintain Worker's Compensation Insurance,as required by Section 3700 of
Labor Code,for the performance of th work for which this permit is issued.My Worker's Total
Compenis�, ° In�su,(�enj�/e�cef(l1e'r entlpPo�lic(y umbar ere: I
Carder t �`rt �/ r �AI�`� 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 less.)
1 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 WorkersCompensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant subject e the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp ant understands and will comp it all non point
with such provisions or this permit shall be deemed revoked. sOurc IffiIODS.
I certify that I have read this application and state that the above Information is correct.I agree �d.Q
to comply with all city and county ordinances and state laws relating to building construction,and All oaf c0 EriI t be class,e_ r better
hereby aulhmlza representatives of this city to enter upon the above-mentlonetl property for In-
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities,
oltlha granlingsts and ol this pePmuses which may In any way accrue against said City In consequence SIGNATURE OF APPLIC 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