00030155 - 0003 sot —
3 - S� 001 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMB
REROOF PERMIT INSPECTION DIVISION PERMIT IRATI
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1a0 DAYS OF PERMIT ISSUANCE OR
10o DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL OMMERCIAL OTHER
OWNER'S _ HAZARDOUS FIRE AREA
`1 YES ❑ If yes—I understand that a Class A
NAME 1 oof assembly is required.
^ V NO Initial I.C.B.O.#
ADDRESS 1Vh EXISTING ROOF COVERING
PHONE ��� NUMBER OF EXISTING RINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS \ ,t(�J� ,p TYPE OF ROOF COVERING
CITY&ZIP p vL
EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE I ASPHALT SHINGLES ❑ /�Q
NUMBER s
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 quaJiless and Professions Code,an my license is in full force and
effect.
LO WOOD SHINGLES ❑
License Clas Lic.Number
�THER (SPECIFY), ❑
Date Contrecto -
.— _
OWNER-BUILDER DECLARATION PROPOSED��_'
I hereby affirm that 1 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 }I D
construct.alter,improve,demolish,or repair any structure,prior to its issuance,also requires the gWILT-UPR 6 vs000 ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions 4 L
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the II✓
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged A$PHHLI JHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant far a permit subjects the applicant to IY
a Civil penalty of not more than live hundred dollars($500).f: 1
❑ Ell,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. -
sions 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 employees,provided that ❑ 1
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 didOTHER(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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
[:jI am exempt under Sec. ,B 8 P.C.for this reason
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of Perjury one of the following declaration: +Lt�,�//
❑ have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, Building�" '
as provided for by Section 37M of the Labor Coda,for the performance of Wtheworkforwhich this I //�f/` W //l/./\ v`Jv`J\
pe_�rm}�s ts issued. ' SeISR11C
,tissued.
and will maintain Workers Compensation Insurance,as required by Section 3700 of c ��J /'�✓�
the Labor Code,for the performance of the work fo which this permit Is issued.My Workers Total `-"t,1 /• V r/
Compensation Insuran a carrier antl Policy numaer e: �".�7
Carrier Policy No. 11� P MIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.G[ �
(This section need not be completed it the permit is for one hundred dollars($100)or less.) Y/
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 Law,of call. All roofs shall be inspected prior to any roofing material being
fornix. installed. If a root is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become A IIC nderstands and willarbe�r.
ith all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP p
with such provisions or this permit shall be deemed revoked. SOuf reg lations.
I certify that I have read this application and state that the above Information Is correct.)agree
to hereby authorize
repty resentatives
county ordinances ces antlstate teruon the
above
mentioned property
All O=gtDhereby lywithlall representatives of this city to enter upon the sing to bedding d property for in-spection purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may In any way accrue against said City in consequence
of the granting of this permit, SI ATURE 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