00050101 2- OeS '
OIO -PERMIT
R
APPLICATION FOR CITY OF CUPERTINO NUMBER "
REROOFPERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228, PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LASTCALLED INSPECTION.
BUILDING ADDRESS �'�\
4OaO FI z CC-241. J RESIDENTIAL COMMERCIAL - OTHER
OWNER'S ( HAZARDOUS FIRE AREA
rlS/ YES ❑ If as—I understand that a Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.A
ADDRESS A js vi.' EXISTING ROOF COVERING
PHONE r� "'S— 31 �j' NUMBER OF EXISTING COVERINGS /
CONTRACTOR/h^
NAME. -�
/t Al TITy.I�/ (�� .I�O� I-•• C,L I/� TO BE REMOVED_TO BE RETAINED
_
ADDR'VSS [/ p (�
�� D ` X ZTGG6 vAAI JOSC TYPE OF ROOF COVERING
CIN&ZIP `-
_ 9S!S5l EXISTING •'
PHONE BUILT-UP ROOF - ❑ ��/
NUMBER �J I �S3 ASPHALT SHINGLES ❑ ®�
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In full force and
effect
License
9 (Q WOOD SHINGLES ❑
Cleanse Claes � � I Lic.Number � I /
Oat. S� I (a -OD Contra cor -1tZQ/tL OTHER(SPECIFY)
❑
OWNER-BUILDER DECLARATION PROPOSED
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 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 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
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of not more than five hundred dollars($500).):
E]1,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-
sionsCode:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES
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 OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusive contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
E)I am exempt under Sec. ,B 8 P.C.for this reason
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 self-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work far which this ///��� p g
pe Ihv and �66d G - Seismic
have and will maintain Worker's Compensation Insurance,ea required by section 3]00 0l ��// „D 66 U
the L bar Code,for the performance of the work for which this permit Is Issued.My Worker's �—O
Compensation Insurance carrier and Policy number are:. /� Total
Carrier c5TAT� FualPolicy NN/O6Oa- S� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 100)o r Iasless.)
(This section need not be completed It the permit Is far one hundred dollars($100)o
I 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 Workers'Compensation Laws of Can- All roots shall be inspected prior to any roofing material being
fornia. - installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
NOTICETO APPLICANT: 11,after making this Certificate of Exemption,you should became Applicant understands and will comply with all non Int
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP p y p0
with such provisions or this permit shell 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 relating to building construction,and All roof,Foveringsto be s' " rbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In e��[J
(W
sp e) purposes. f
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabllitles,
judgments,costa and expenses which may In any way accrue against said City In consequence
of the granting of this permit. SIGNATURE 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 ACCESS TO'ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY