R 5010i
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OFFICE CnPV
PERMIT j;_ 5 010
NUMBER
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMITEXPIRATION
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 ADDRESS
ZI (P 0 at G—DLZ) 0-eA
RESIDENTIAL COMMERCIAL OTHER
OWNERS
HAZARDOUS FIRE AREA
YES ❑ If yes – I understand that a Class A
NO roof assembly is required.
d tial LC.B.O. k
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24(po �""
OF 1✓,�yJ
ADDRESS — " 1✓ .' IIEXISTIN
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=�S
PHONE ZSG=�>,2Z.
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
6
'
_
n
NAME 1Z-PMc.�SS061111,Jc9r "1)y Lir r .
TO BE REMOVED TO BE RETAINED
Illnv
TYPE OF ROOF COVERING
ADDRESSL} n
CITY & ZIP Z2 012 � uq k N _
EXISTING
Q ^/1
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PHONE -
BUILT-UP ROOF El
q
LICENSE l 3
NUMBER G 3 1
ASPHALT SHINGLES C31
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
7000) of Division 3 of the of and ProfsSalone Code, and my license Is In full force and
effect' /���111 31 3
�
WOOD SHINGLES ❑
License Clea , U Numb J
6
OTHER (SPECIFY) ❑
Date Contra _
OWNER.BUIL E,AARATION
I hereby affirm that I em exempt from the Contractor's License Law for the following reason.
PROPOSED
(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 ❑
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law (Chapter B (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 tar a permit subjects the applicant to
e civil penalty of not more then five hundred dollars ($500).1:
❑ I, as owner of 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 Profes-
alone Code :The Contractor's License Law does not apply to an owner of property who builds or
thereon, and who does such work himself or through his own employees, provided that
WOOD SHINGLES 1:1Improves
such Improvements are not Intended or offered for sale. II, however, the building or Improvement
Is sold within one year of completion, the owner -builds, will have the burden of proving that he did
OTHER (SPECIFY) 1:1not
build or Improve for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with Ilcensetl 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 bultds or Improves thereon, and who contracts for such projects
with a contrectofts) licensed pursuant to the Contractors License Law.
❑ I am exempt under Sac. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have and will maintain a Certificate of Consent to sell -insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
Is Us
BUlldlI�
/ O /� I,
Xrml
1 have antl will maintain Worker's Compensation Insurance, as required by Seetlon 3]OO of
3 V SBIStnIC
e bor Code, for the performance of the work for which this permit Is Issued. My Workers
Compensall Insurance carrier antl Polio number are:
Carrier ' �L...� q
Total
Policy Nezas— 1
PERMIT AUTHORIZAT Jl DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.0
(This section need not be completed If the permit is for one hundred dollen ($100) or lees.) .
I certify that In the performance of the work for which this permit Is Issued, I shall not employ
In &II.
All roofs shall be inspected prior to any roofing material being
any person any manner so as to become subject to the Workers' Compensation Laws of
forma,
installed. If a roof is installed without first obtaining an
Dale Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisionsApplicant
of the Labor Code, you must forthwith Comply
- A understands and will 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
Alir eringS SS"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
a
ap purposes.
/
(We) agree
(We) neve, Indemnify and keep harmless the City of Cupertino against liabilities,
/
judgments, coats and expenaes which may In any way accrue against said City In consequence
of the granting of this permit.
SIMATURE OF APPLICANT 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 CnPV