0001001101-001
/Y�OY PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
MARIM
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
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ADDRESS
NAMES `� J/� `' �� • �F
ADDRESS
2—CI
CITY BZIP /)Q Uy)/ ✓\/'� j[�` /.�•1�\ l�-1
PHONE 0`s ( ( V
LICENSE- 25/ �� �.
NUMBER ..7
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
]000) of Division 3 of the Business and Professions Cotle, and my license is in full force and
effect.
License Class A Lit. Number
Date Contractor
OWNER -BUILDER DECLARATION
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
applicant for such permit to fila a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section ]000) of Division 3 of the
Business and Professions Code) or that he is exempt therefrom and the basis for the alleged
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).):
❑ I, 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 Cotle: 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 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
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
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.
[] I am exempt under Sec. .B & P. C. for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:'
I] I have and will maintain a Certificate of Consent to self -insure for Worker's Com
as provided for by Section 3700 of the Labor Coca, for the performance of the work forpe w
permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
the Labor Code, for the performance of the work for whlch this permit is issued. My 4
Compensation Insurance carrier and Policy number are:
Carrier Policy No. % Oy
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.00]
(This section need not be completed If the permit is far one hundred dollars ($100) or less.)
I certify that in the pertormanca of the work for which this permit is issued, I shall not employ
any person in any anner so as to became subjeation Laws of Cali-
fornia.
Date ^ Applicant J\
NOTICE TO APPLICANT: If, atter making this Certifica a of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shall be deemed revoked,
I certify that I have read this application and state that the above information is correct. ) agree
to comply with all city and county ordinances and state laws relating to building construction, and
hereby authorize representatives of this city to enter upon the above-mentioned
property kr in -
(We)
purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against liabllities,
judgments, costs and expenses which may in any way accrue against said City in consequence
of the granting of this permit.
PRE -INSPECTION: PIYWnnn
DATE INSP. _
INSPECTION: BATTENS:
INSP.
RESIDENTIAL \ COMMERCIAL OTHER
YES ❑ If yes - I understand that a Class'A
roof assembly is required.
NO Ir l
NUMBER OF EXISTING
COVERINGS
TO BE REMOVED V /v `Y7g gAINED
TYPE OF ROOF COVERING
EXISTING
PROVIDE MFGR. INSTALLATION SPECS.
VALUATION I PERMIT FEE
u t�C� Building
JAN 82000 Seismic
Total
PERMIT AU IZATION nATF
Ali roors snag Be Inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
sourotil regulations.
All of coverings class "C" or betterq
SIGNATUHL OF APPLICANT DATE
IN -PROGRESS:
INSP. DATE
FINAL:
NOTE- OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE:COPY