00040140 s 0004-o
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_'
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777-3'2'26 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IN DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
1! VES ❑ If yes—I understand that a Class A
NAME V roof assembly is required.
NO C3Initial I.C.B.O.k
ADDRESS F�r V 1 EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S 1
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS v �h TYPE OF ROOF COVERING
CITY a ZIP EXISTING
PHONE BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSEDCONTRACTORSDECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
]000) f Division 3 0l 1 iness and Professions Cade,a d icense is in lull lone and
o
affect. WOOD SHINGLES El
License Cla Lic.Numbar
Data Z contractor M- J nVJJAA Ll(C OTHER (SPECIFY)
OWNER BUILDER DECLARATION ROPOSED / I�
hereby affirm that I em exempt from the Contractor's License law for the IPllowing reason. Ar
` {�
(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 El0
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
a civil penalty of not more than live hundred dollars($5001 WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Proas-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑ �l
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,em 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.
C]I am exempt under Sec. ,B 8 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:
❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, I (y1 '^ ^� Building
as provided for by maintain
a Citta Labor Code.lot thepednsure for
of Worker
for whicthish /WI Cl_ (`/N`J\`J\
p 1 ,2
it is issuetl.
ve and will maintain Worker's Compensalion nsuranl, a a requiredby Section 3700 o1 $eISmIC
I Labor Code,for the performance of the work for hich this permit is issued.My Workers
Compensation umnce carrier antl 'cy number a Total
Carrier Policy No. . - �— PERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ % / {'
(This section need not be completed H the permit Is for one hundred dollars($100)or less.) C!/ 21—6
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 Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
lornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new mater' for inspection.
NOTICE TO APPLICANT: 11,cher making this Certitude of Exemption,you should become A licant lands and will Com with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must lonhwilh comply PP P P
with such provisions or this permit shall be deemed revoked. SOUrc gulatl0 S.
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 stale laws relating to building construclion,antl All r f coverin to be lass 6 or etter.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection Purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, It il
judgments,costs and expenses which may in any way accrue against said City in consequenceATURE OF APPLICANT DATE
of the graining of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
. ,INSP. DATEINSP. DATE INSP. DATE
t TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. "r ''x DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY