R 7591 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R' ' 1 Til n
J J
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408).777-322.8 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF.PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESSVie
/
032 D v _ T .RESIDENTIAL COMMERCIAL OTHER
OWNER'S // �q � 11' - .HAZARDOUS FIRE AREA
NAME 2f'1'�P I L K Mfg fg R 12.N VES ❑ If yeas asseundembly
i reqand that. Class A
roof assembly is required.
- •�,. /+ / NO ElInitial I.C.B.O.If
ADDRESS. Z0 3 2O [/�- l'1U`e^'r1 - r �ZKtx +, Xh 0 EXISTING ROOF COVERING -
PHONE - 01 Ct `I .3 —I y - � NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
PHONE BUILT-UP ROOF
LICEER B
NUMASPHALT SHINGLES El
LICENSED
-
.. P. LICENSED CONTRACTORS DECLARATION tall I hereby 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. WOOD SHINGLES ❑ '
License Class Lic.Number
- 'Date Contractor
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
appllcanf for such permit to file a signed statement that he is licensed pursuant to the provisions f
.of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 at the-
• Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES.' Eli
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)):- WOOD SHAKES
El 1,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes-
sions Cod e: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 ❑ r
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.). ,
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.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 -
withacontractor(s)licensed pursuant to the Contractor's License Law - PROVIDE MFGR. INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P C.for this reason ,
7C•Owner - _ Data APPLICATION DATE VALUATION ' PERMIT FEE
WORKER'S COMPENSATION DECLARATION
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, 2100 0
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Building_ - 4
permit is issued. $eISR11C
[-]I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 1 T
the Labor Code,for the performance of the work for which this permit is issued.My Worker's - ` [.J
Compensation Insurance carrier and Policy number are: - Total (
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' -
.COMPENSATION INSURANCE N.CC3 e -
(This section need not be completed if the permit is for one hundred dollars($100)or less.( JQ p 7 -
I certify that in the performance of the work for which this permit is issued, shall not employ ` - -
• any person In any manner so as to became subject to the Workers'Compensation Laws of Cali- : All roofs shall be inspected prior o any roofing material being
handle. installed. If a roof is installed without first obtaining an
Dated✓l��trkD Appkcant L inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,afteral
this Certificate of xemption,you should become,
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply. Applicant understands and WII Comply with all non point
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 agree '/]x�`
to comply with all city and county ordinances and state laws relating to building construction,and ' All roo Coverings s Vaclass better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. _ 0 ro
(We)agree to save,indemnify and keep harmless the City ai Cupertino against liabilities,
ofthe gran casts antl expenses which may in any way accrue against said City in consequence
of the granting of this permit. � . •SIGNATUHEUFAPPLICANT `' 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
` OFFICE COPY - -