R-39934b
APPLICATION FOR
REROOF PERMIT
�PeT.IY:7F:
NAME 1. 11 1 1n
ADDRESS Sa
PHONE 7 3 Z _' cl I
NAME t --U U 1 In
ADDRESSn
CITY 8I ZIP .I L
LD S G� `owpn
PHONELICENSE
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NUMBER H 7. 4/ CI
CITY OF CUPERTINO
INSPECTION DIVISION
(408)252-4505 EXT. 228
LICENSED CONTRACTORS DECLARATION
I hereby stfbm that I am licensed under provisions o1 Chapter 9 (common.
cling wish Section )0001 01 Division 3 of the Bulinus and P.obul ons Corte,
end my license i Jn irce ane effect.
andLicensemy Clen ` Lic. Number
Date Cont,.,.,
OWNER -BUILDER DECLARATION
I neroby affirm that I am exempt from the Contractor's License Lew for
the lollowing reason. (Sac. 7031.6, Business and Professions Coda: Any city
or county which requires a permit to construct, altar, improve, demolish,or
repair any structurart
, prior to . issuance, also requires the applicant for such
permit to file a signed statement that he is licensed pursuant to the provisions
of "T0te Contractor's License Lew (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code) or that he is exempt there
from and the basis for the alleged exemption. Any violation of Section
7031.6 by any eppl icant for a permit subjects the applicant to a Civil penalty
of not mora the, five no Pored dollen ($600).1:
❑ I, e• owner Of This property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended q offered
for sale (Sec. 7044, Business and Profusions Code: The Contractor s License
Law don not apply to an Owner Of property who build$ or improves thereon,
and who does such work himself or through his own employees, provided that
such improvements
are not intended o offered for sale. If, however, the
building or improvement is mid with in ro one year of completion, the owner
builder will nava the burden of proving that he did not build or improve for
purpose of •$iasis
❑ I. e• owner of ma property, a xclu•ively contracting with licensed
con ."Or:
In c ns"o" the project (Sec. 7044, Bmines• and Professions
Code: The Contractors License Lew does not apply to an owner of property
who build, or improves thereon, and who contracts for such project. with
otorls) licensed
a
cntraccensed pursuant to the Contractor se s LicenLaw.
❑ 1 am exempt under S.C. ,B.&P.C, for this
asion
Owner Det.
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -Inure, o
lificab o1 Work.,. C.mp.... lion Insurance, o Certified copy thereof (Sec.
3800, Lab. C �-s /� //J�
P011cy No. I 3 / Company(1,21 ' L;O h
Certified copy is hereby furnished.
Certified copv i• filed with me city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C. 0
(This section need not be completed if the permit is for one hundred dol
an, 15100) or And.)
I certify that in the performance of the work for which this permit is
issued, I •M1 ell not employ any person in any manner w as m become object
to ma Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: 11, after making this Certificate of Exemption,
you should become subject to the Workers Compensation provi.i one of the
Labor Code, you mutt forthwith comply with such provisions Or this permit
shell be
doomed revoked. .
Icantity that 1 have read this application and stele That the above informs
tion is correct. I agree to comply with all city and county ordinances and
sun laws relating to building construction, and hereby aulhont. wpreDo-
utivas of this city to enter upon the above mentioned property for inspection
purpose,
we) agree to save, indemnify and keep harmless the City o1 Cupertino
against liabilitin, judgments, costs and expenses which may in any weer accrue
.gains, said City in consegwnca of the granting of this permit.
PERMIT R. 3993
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYSOF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
AL OTHER
ROOF
COVERING
CLASS _
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
TO BE
EXISTING
% r /
ASP LE C
D $N/4K
D S\H IIINN ES f3
0 PECIF'ap
PROPOSED /I 18 �9 Is
c y� g
BUILT-UP ROOF 'Luray%
ASPHALT SHINGLES
WOOD SHAKES
WOOD SHINGLES
OTHER (SPECIFY)
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.!n
/ ?--IF S I/ 0, 400
PERMIT FEES
ilrlinn� \1/
All roofs shall be inspected prior to any roofing material being
installed If a roof is installed without first obtaining an
inspectio gree to remove all new materials for inspection.
SIGNATURE OF APPLTCANT ' 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
FFICE COPY