00050132 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBST{ S�3
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(406).777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1 B DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS q , ///
1 - -/6 1l I r/ lJ I RESIDENTIAL` COMMERCIAL _ OTHER
II OWNER'S HAZARDOUS FIRE AREA
- `/ YES
NAME J 0 lr -` Y�o� t �(JlD f TG'— ❑ If yes—I understand that a Class A
roof assembly is required.
p- 7 NO ❑ Initial I.C.B.O.H
ADDRESS- /l,0.y/,- l.�rr, /37,;� AI) - EXISTING ROOF COVERING
PHONE / O� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S - n
NAME Cllow''s - _/4'i�jF%`/� TO BE REMOVED TO BE RETAINED -
ADDRESS trA OTYPPE OOF COVERING -
CITY&ZIP
�O �d ��rG� •-� ��' . z3 EXISTINPHONEBUILT-UPR
LICENSE �'�
NUMBER 7 - - ASPHALT SHINGLES
- -. "LICENSED CONTRACTORS DECLARATION
I hemby`affirm that I am licensed 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
effect. _
?? � '
License Class � L� Lia Number 3,? �3 � -WOOD SHINGLES El . . '
Date Contractor 4.931 d2>i / bkyF/o/6 OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am 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 Q
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions - -
of the Contractors 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).):
EJ 1,as owner f 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 Pmfes- - -
sions Code: The Contractor's License Law does not apply to an owner of property who builds or WQQDSHINGLES
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.). (SPECIFY)
❑I,as owner of the property,am exclusive contracting with licensed contractors to construct
the project(Sec,7044,Business and Professions Code:The Contractor's License Law does not ' PROVIDE I.O.B.Q.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects -
with a contractor(6)licensed pursuant to the Contractor's License Law. .
❑1 am exempt under Sec. ,B&P.C.for this reason PROVIDE MFGR.'INSTALLATIQN SPECS.
Owner Date
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 Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this g
permit is issued. - '. ,p'
❑ have and will maintain Workers Compensation Insurance,as required by Section 3700 of ye Q Seismic
the Labor Code,for the performan of the work for which this p90nit'-- �O/
Compensation or the carrier a tl ahoythe
number are: L TOS2I
rzb
'Policy No. PERMIT AUTHORIZATION' - DATE
CERTIFICATE OF EXEMPTION FROM WORKS S'
COMPENSATION INSURANCE N.C.O
(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 Call- ' All roofs shall be inspected prior to any roofing material being
forma. 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 with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP p y
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.)agree (/�J •�-
to comply with all city and county ordinances and state laws relating to building construction,and All to rings to be class'Ti or better. . -
hereby authorize representatives of this city to enter upon the above-mentloned property for in-
spectiou purposes. . , `
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses Which may in any way accrue against said City in consequence DATE
of the granting of this permit: SIGNATURE OF APPLICAN
PRE-INSPECTION: - PLYWOOD: - - r IN-PROGRESS: -
fNSP. 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
OFFICE COPY, - - -