99100155 APPLICATION FOR CITY of CUPERTINO .
REROOF PERMIT INSPECTION DIVISION UPERMITFS111RAT101
l' ." - (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180CAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS -
1•02-eoO �jJE� .�. ESIDENTIAL COMMERCIAL OTHER
- - OWNER's - t.1} - -' HAZARDOUS FIRE AREA-
NAME - `` YES f7 .Ifyes—Imbly is required. Class
roof assembly is and that
1��q,�� NO Initial I.C.B.O.N
ADDRESS 'Z--S�O `""""�'t�' �t�•at Sr (d'O' - EXISTING ROOF COVERING
PHONE - - NUMBER OF EXISTING COVERINGS
CONTRACTOR'S-. - - - -
�x�x '- CO- TO BE REMOVED TO BE RETAINED
NAME GV•��l�c%R-V�.t 14- ��� � C .
ADDRESS TYPE OF ROOF COVERING
CITY&zip SQ Z9 S. ko " . ST= <;,rs, C
EXISTING
PHONE . :OZ 213 ---7917 7 BUILT-UP ROOF ,
LICENSE 'r
NUMBER, ASPHALT SHINGLES ❑
- -
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensetl 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
effec "
t.
WOOD SHINGLES ❑
License Class 4 .- C) Lip.Number ' (I4 900 y
Date IZ-- 000 Contractor c"-%1 OTHER(SPECIFY) - ❑
OWNER-BUILDERDECIARATION-- PROPOSED -
I hereby affirm that I am exempt from the Contractor's License Law for the following reason, '
" (Sed703 1.5,Business and Professions Code: Any city or county which requires a permit to
consiruct,alter,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 PHALT SHINGL Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged AS
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($501
❑l,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES�� '
the work,and the structure isnot intended or offered for sale(Sec.7044,Business and Proles-
alone Code:The Contractor's License Law doesnot 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 0 ❑
such improvements are not intended or offered for sale.If,however,the building or improvement - -
issoldwithinoneyearofcompletion,the owner-builder will have the burden ofproving that hedid OTHER(SPECIFY)
not build or improve for purpose of sale.). -
1]1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sea 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 correctons)licensed pursuant to the Contractor's License Law.
E] PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B&P,C.for this reason
Owner - Date
.WORKER'S COMPENSATION DECLARATION �• APP 9� ION OATE IALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: {� O
E] ve I haand will maintain a Certificate of Consent to self-insure for Worker's Compensation, u BDIdIn
permit is issued.
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this OCT � $1999 .V , -o
have and will maintain Worker's Compensation'lnsurance,as roamed by Section 3700 of Seismic 'J
this'La Code,for the performance of the work for which this permit is issued,My Worker's r'r^/'/ �-y a�
co pe:js ion insurance carrier antl Fri ur bar are:, Total �> / . J o
rrierT 2�` olicy No.5 �4 O��� B ION ' DATE-
CERTIFICATE OF XEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.
(This section need not be completed if the permit is for one hundred.dollars($100)or less.) �O•' Ltv(''/\
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 Workers'Compensation Laws of Cali. All roofs shall.b6linspected prior to any roofing-material being
forms 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 understands and will comply subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp ply with all non point.
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that l have read this application and state that the above information is correct.l agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof cov ri s'tobe lass"C'or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
'spectionpurposes..
(We)agree to save,Indemnify and keep harmless the City of Cupertino'against liabilities, Ib Z
juagments,casts and expenses which may in any way accrue against said City m consequence
of
III oI this permit. SIGN OF A LI T- -DATE '
PRE-INSPECTION: PLYWOOD:
INSP. - DATE - INSP. DATE - INSP.- DATE
TEAR OFF INSPECTION: i, BATTENS: .. FINAL: -IN SP' - - .DATE - - INSP. 1 DATE .. INSP. - DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION.
- OFFICE COPY