00010026Is
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fiP 3.5 % — — D l PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R"
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INSPECTION DIVISION PERMIT EXPIRATION
- REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
_ 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESSCQ p-0'2__.;_1
2otw8 Z
RESIDENTIAL- COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ElII yes — I understand that a Class A
—1
NAME v'• Q
roof assembly is required.
NO ❑ Initial - I.C.B.O.If
ADDRESS
EXISTING ROOF COVERING
/
[meq'
PHONE
NUMBER OF EXISTING COVERINGS
- —21�
TO BE REMOVED 5� TO BE RETAINED
CONTRACT
NAME c//'Y�J/ H
ADDRESSE9^ S�aS
TYPE OFR OF ERING
CITY B ZIP 7 •'
EXISTING
p \ 706 - )S:3 7
PHON /;-5/
BUILT-UP ROOF
,
LICENSE 2¢
NUMBER % B - C /
O
ASPHALT SHINGLES - d
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0 (commencing with Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license Is In lull force antl
effect'
R 7
7 ? -
WOOD SHINGLES - ElLicense
Class Llc. Number V
OTHER (SPECIFY) ❑
Date Contractor
PROPOSED
OWNER BUILDER OECL
hereby affirm that License
am exempt from the Contractor's License Law for the following reason
(Sec. 7031.5, Business and Code: Any city or county which requires a permit to
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demolish, or rep
construct, alter, improve, to file signed statair eny menthatstructure, Is licenseor to issuance, also requires s the
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
BUILT-UP ROOF f] -
of the Contractors License Lew (Chapter (commencing with Section 7000) of Division 3 of the
JA,
N 7 2000
D
Business and Professions Code) or that he is exempt
h and the basic for the alleged
ASPHALT SHINGLES ❑
exemption. Any violation of Section by any applicant for a permit subjects the applicant m
antfora
e civil penalty of not more than five hundred tlollnre ($500),I:
hundred
L] 1, as owner of the property, or my employees with wages as their sole compensation, will do
'
WOOD SHAKES gy
the work, and the structure is not intended or offered for sale (Sea 7044, Business and Proles.
sloes Code: The Contractor's License Law does not apply to an owner of property who builds or
improves thereon, and who does such work himself or lh rough his own employees, provided that
WOOD SHINGLES ❑
such improvements are not intended or offered for sale. If, however, the building or improvement
_ -
'�j��[C•
is sold within one year of completion, the owner-bullde r will have the bu rden of proving that he did
OTHER(SPECIFY) '
not build or improve for purpose of sale.).
— I
E] 1. 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. A S 2 i G
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a contractors) licensed pursuant to the Contractor's License Law,
PROVIDE MFGR. INSTALLATION SPECS,.
Olathe xempt under Sec. ,B'8 P. C. for this reason
,
Owner - Ante
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
01 have and will maintain a Certificate of Consent to self -insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
0-0
q
Building
Ave and will maintain Worker's Compensation Insurance, as required by Section 3700 of
I6bor Cotle, for
Seismic
the the performance of the work for which this permit is issued. My Worker's
Compensation s artier and Policy nu rare:
--
Total .
Carrier 0I>PolcyNo.%✓ X9933
PERMIT AUTHORIZATION
DATE
• CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE N,C.I]
(This section need not be completed if the permit is for one hundred dollars ($100) or loss.)
%
I certify that in the performance of the work for which this permit is issued,`hall not employ
any person In any manner se as to become subject to the Wprke ompensaunn 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 7 Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TOAPPLICANT: If, after making this Cortical of xemption, you should become
subject to the Workers' Compensation provisions of the Lebo ode, you must forthwith comply
Applicant understands and will comply with all non point
pP P Y P
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. I agree
to comply with all city and county ordinances and state laws rotating to building construction. and
All roof coverings to be class "C"or better."
hereby authorize representatives of this city to enter upon the above-mentioned property to, int
spection purposes.
(We) agree to save, indemnity and keep harmless the City Cupertino liabilities,
-7
. of against
judgments, costs and expanses which may In any way accrue against said City in consequence
at the granting of(his permit.
100
SIG ATURE fY PPLICANT AT
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
OFFICEICOPY