6013 APPLICATION FOR CITY of CUPERTINO NUMBER
REROOF PERMIT' INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228: PERMIT EXPIRESIFWORK IS NOT STARTED' ,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING AADDRESS j \' ' -\
q71, L.IL_\1 AvCc�NU�. • - �RESIDENT'll- COMMERCIAL OTHER
OWNER'S' / HAZARDOUS FIRE AREA
NAME 13\� �,6� VES ElIf yes-I understand that a Class A
roof assembly is required.
,/ -
NO Elinitial I.C.B.O.#
ADDRESS O •4�� - LI L\1 . A06,005'
EXISTING ROOF COVERING
PHONE / �..-7 I - 'NUMBER OF EXISTING COVERINGS I
NAME GiJI�IS� IL.Lt7�lN(x l d I, iL_ TO BE REMOVED TO BE RETAINED
ADDRESS5 TYPE OF ROOF COVERING
L
CITU BZIPZ9 /J
2 � I coves Avt�
EXISTING .
PHONE BUILT-UP ROOF
LICENSE 5/�G X22 ❑
NUMBER Il 7 .J ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 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 Class��_ LIC.Number 'WOOD SHINGLES
Date - -• contractor 'r✓ OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractors License Law for the following re son.
(Sec.7031.5,Business and Professions Cotle:.Any city or county which requires a permit to
construct,alter,improve,demolish,or repair any structure,prior to Its Issuance,also requires the - UILT-UP ROOF ❑
applicant for such permit to ills a elgnatl statement that he Is licensed pursuant to the provl xcns -
of the Contractor's License Lew(Chapter 8(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 HALT SHINGLE$ ❑ '
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to f
a civil penalty of not more than fivehundred dollars($500).):
❑l,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 Lew 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 ❑ guy
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 0THER(SPECIFY) ;•� •
not build or Improve for purpose of sale.). - -
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the Project(Sec.7044,Business and Professions Code:The Contractor's Llcenae.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.
C] P. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec, ,B 8 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: �nf ne ■■ ,pt
❑i have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation,, T s5 ) k` BUllding
. as provided for by Section 3700 of the Labor Code,for the performance of the work for which this p -�
permit is issued. `,` I
have and will maintain Workers Compensation Insurance,as required by Section 3700 of V O Seismic Q
„ih L tier Cotle„for the performance of the work for which this permit Is Issuatl.My Workers vy n Q
Compensation Insurance carrier and Policy number are: ` y ./ Total
Carrier ' FOiU policy No, lal]Azho3 I@ERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
. COMPENSATION INSURANCE N.C.0 T `
,-(This section need not be completed If the permit is for one hundred dollars($100)or less.) i Q
I certify that in the performance of the work for.whlch this permit Is Issued,1'shall not employ ,
- any person In any manner so as to become sub et hi Workers'Compensation Laws of can- All roofs shall be inspected prior to any roofing material being,
fertile. n 3 - f installed. If a roof.is installed without first obtaining.an
Date 3 - J - Applicant s • ins e"'on,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become (((]]]\
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply ^Plicant understands and will comply with all non point
' with such provisions or this permit shelf;be deemed revoked. ”- - SOUfCe tIODS. '
car tifythat isions re Ithi permit shatl l0b de state that the dabove Information Is Corfeet.l agree
to comply with ail city and county ordinances and state laws relating to building construction,an tl �`ap AI O rin to a class�Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- VN.
spection purposes. .- .. .- t t U
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, . g
LO
judgments„costs and expenses which mey In any way accrue against said City in consequence (�\t`i SI NATURE CF APP I DATE`
of the granting of this permit.
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' ..