00010102 3 - ag - bfS- :Ai-- OboI Oro
PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMITEXPI
REROOF PERMIT RATION
(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
. /03 / 3
L Q3 ` 3 G ' �� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
''II YES ❑ If yes-I understand that a Class A
NAME Y root assembly is required.
NO ❑ Initial I.C.B.O.41
ADDRESS EXISTING ROOF COVERING
PHONE ZS IF 5,1NUMBER OF EXISTING COVERINGS /
CONTRACTOR — n- 4
NAME _ X K.v�.+ TO BE REMOVED TO BE RETAINED
ADDRESS 7QGO (\n - Q'/ TYPE OF ROOF COVERING
CITY&ZIP f0 �J 7'rJ
EXISTING
PHONE� �Cf Y�Q�O Z. BUILT-UP ROOF
LICENSE
NUMBER �� ASPHALTSHINGLES
LI ENSED CONTRACTORS DECLARATION
hereby affirm that I em licensed and
Pr fessiprovisions of Chapter 9(commencing with Section WOOD SHAKES
71100)of Division 3 0l the Business antl Professions Code,end my license is in lull force and
affect.
n L� WOOD SHINGLES
License CI C-3 Lic.Number • Fr/�
Date contraamr r OTHER(SPECIFY)
OWNER-BUILDER DECLARATICAPROPOSED
I hereby affirm that I am exempt[rare 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
applicant for such permit to file o signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(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 El
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penally of not mora than five hundred dollars($500).1:❑l,as owner of the property.or my employees with wages as their sole Compensation,will do WOOD SHAKEE::
PJ /
the work,antl the structure is not intended or offered for sale(Sec.]044,Business and Profen. EJ
sions Cotle:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLimproves thereon,antl who tloes such work himself or through his awn employees,provitletl that i 2000such improvements are not Intended or offered for sale.ll,howeverthe building or improvementlase Id within one year al completion,the owner-builder will have the burden of proving that he ditl OTHER(SPECT ❑not build or improve for purpose of sale.).❑1,as owner of the property,am exclusively contracting with licensed contractors to constructthe project(Sec,7044,Business end Professions Cade:The Contractor's License Law tloes not PROVIDE I.C.B.apply to an owner of property who builds or improves thereon,antl who contracts for such projectswith a contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGATION SP
❑1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: -oO
❑ mp
I have and will maintain a Certificate of Consent to selNesure for Worker's Coensation �� Building
as provided for by Section 3700 of the Labor Code,for the performance of the Work for which t1i / (•y' ,{
permi isiesuetl. Seismic
ave antl will maintain Workers Compensation Insurance,as required by Section 3700of
theabor Code,for the performance of the work for which this permit is issued.My Worker's Total
Campania��ti//o9q//nsu c terrier antl Policy mbar are:
p
Carrier LL Policy No.� 30 2-1)o IS 7'j PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed if the permit is for one hundred dollars($100)or lass.)
1 certify that In the performance of the work for which this permit is issued,I shall not employ "
any person in any manner so as to become subject to the Wo rs'Compensation laws of tali- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
00 Applicant inspection,I agree to remove all new materials for inspection.
Date -
NOTICE TO APPLICANT: If,after making thin Certific a of Exemption,you should become Applicant understands and will I with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP comply y P
with such provisions or this permit shall be doomed revoked, source regulations.
I certify that I have read this application and state that the above Information is correct.I agree
to hereby ly author allze rep and county of This city to enter
upon the
ing totrove-buildingantied property
and All roof co art to be class°C"or better. /
hereby authorize representatives of this city t0 90tef 0p0n th0 above-menllonotl property for In- r // l
specfion purposes. r
(We)agree 10 save,indemnily and keep harmless the City at Cupertino against liabilities, Zr ��
judgments,costs and expenses which may in any way accrue against said CityIn consequence
• of the granting of this permit. SIGNATUR OF APPLICA 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