00010077 3 c`o ' Z6
PERMIT R_
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
UI
7 / r RESIDENTIAL COMMERCIAL OTHER-
OWNERS
THER
OWNER'S// / / HAZARDOUS FIRE AREA
NAME �lr �.L�¢u/o rd a YES ❑ If yes-1 understand that a Class A
roof assembly is required.
/ NO ❑ Initial I.C.B.O.4
ADDRESS S�Z /'l a��Gv�A ru EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS h
CONTRACTT
NAME W Cf 1SS4NGP nn rZ�rd'om�'' TO BE REMOVED ; �M TO BE RETAINED 7f� Cfl
/tta
ADDRESS / XtTYPE OF ROOF COVERING
CITY&ZIP 22'77 Lit W ��``„3
WOO
EXISTING
PHONE WOO 7 BUILT-UP ROOF
LICENSE - /
NUMBER �} �Co 935,p_ ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION El /C)
hereby affirm that em licensed under provisions of Chapter y(commencing with Section WOOD SHAKES
]000)of Division 3 0l the Business and Professions Code,and my license is In full lona and
effect.
•�
License Class C.,35 Lie.Number SZ WOOD SHINGLES
Date -30'2P0* Coma-- ,G.. OTHER (SPECIFY) C_O
OWNER BUILDER DECLAR IO PROPOSED rl •,
hereby affirm that I am exempt from the Contractors License Law for the following reason, u
(Sec.7031.5,Business and Professions Cotle: Any city or county which requires a permit to
P.applicant
alter,improve,demto file signed airstatement
anystructure,Is licenor tose issuance,to theprovisions
requires the BUILT-UP ROOF D
applicant for such permit a lila a signori statement nci he Is licensed pursuant m the provisions
Lf N
of the Contrectots License Law(Chapter B(commencing with Section]000)of Division 3 01 the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHIN ir):s JAN 133000
Plan.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to u
a civil penalty of not more than live 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 Profen
.ions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLESEY -- A
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 huddling or improvement /�
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) vl^ `�6
not build or Improve for purpose of sale.).
tv
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.]044,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 buiIds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law.
L] PROVIDE MFGR.INSTALLATION .SPECS.
I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
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 Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. 9
"I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of D//J•f axzsi V Seismic
the Near Code,for the performance of the work for which this permit is issued.My Worker's / e9 / /1
Compensation Insurance carrier d Po cy nu ber are: Total /
Carrier �,y{Q,.-t�(.yr �O '. 'c>h Policy No. SID.,f?['y12?�5s'��' PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be
completed if the permit is for one hundred dollars($100)or less.)
1 certify that In the performance of the work far which this per it is issued I shall not employ
any person in any manner so as to become sublect to the o k Compensation Laws of Cali. All roofs shall a inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Data 1 -13-00 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter making this Cert, to xemplion, u should become A llcant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y
with such provisions or this permit shall be doomed revoked. Source regulations.
I certify that I have read this application and slate that the some Information is correct.I agree
to comply with all city and county ordinances and state laws rotating to building construction,and All roof coverin s O ISclass- or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spaction purposes. )
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way aCCi against said City In consequence
of the granting of this permit SIGNE A (CANT 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