R 5085 PERMIT R_ 5 0 8 5 .
APPLICATION FOR CITY OF CUPERTINO NUMBER
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 ADDRESS
l/n I�j///1 �/
/ v{/ f O RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME O 4� mof assembly is required
;ial LC.B.O.a
ADDRESS v/ (/� ITJ EXISTING ROOF COVERING
/
PHONE [ �- /� Ov/ NUMBER OF EXISTING COVERINGS
CONTRALTO 'S /9Wy 1
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS �/ 7 //���� n' F I
CITY&ZIP [` �7 y�yg1� /y� cn/�J� EXISTING
PHONE -//D g�,f 7-70 BUILT-UP ROOF ❑
LICENSE
NUMBER ® ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES El /i
7000)of Division 3 of the Business antl Professions Code,and my license le In full force and
affect. /
WOOD SHINGLES
License Class LIC.Number
Date Contractor
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 lila a signed statement that he Is licensed pursuant to the provisions
of he Contractor'.License Law IChoprer 0(commencing with Section 7000)of DIvlBlon 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
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 WOOD SHAKES ❑
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Proms.
alone Code:The Contractor's 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 employee.,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 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.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(.)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATEJ VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: - :,
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, i y7
as provided for by Section 3700 of the Labor Cade,for he performance of the work for which this Building
permit is Issued. `w V/ t 1jjj���i/q /
❑I neve and will maintain Workers f the work
for which
this as required by Section 3700 of /I // bbb 9 ' / /nF/�996 seismic
.the Labor Code,for the performance of ho work for which this permit Is Issued.My Workers /�!/SJ YY (/�/
Compensation Insurance carrier and Policy number ere: it I� t rP l.Ui G I I IRI I Total
Carrier Policy No. PIERM!YAUTHOFIITION PATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is for one hundred dollars($100)100)or lees.)
I certify hat In the performance of the work for which le permg Is Issue II not employ
any pars In any man a.to become subje t to ewe ,ir cat Laws of call- roofs shall be inspected prior to any roofing material being
ro`nIa' 2 o einstalled. If a roof is installed without first obtaining an
oat / Applicant inspection,I agree to remove all new materials for inspection.
become
subject to the Workers'Compefnsation provisions of theafter makis CarlLaborr Cotle,ears you must forthwith comply Applicant understands and comply with all non point
with such provisions or this permit sraffbe deemed revoked. source re lations.
1 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 refining to building construction,and All roof Dive • s aclass"C"or better.
hereby authorize representatives 0l this city to anter upon the above-mentioned property for In.
hpecuon purposes,
(We)agree to save,Indemnify and keep harmless he City of Cupertino agalmi Ilabllities,
judgments,coats and expenses which may in any way accrue against said City In consequence
of the granting of this permit. MATURE QF�APIIXICANT 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