99110148 3S1 S � Cj ( i
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBS
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
�s\ V�TIt7VG RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�`�� �•-,\>,�,r\,.y�� YES Cl If yes—I understand that a Class A
NAME \V M"�tCJ�> mM assemdy is required.
NO ❑ Initial I.C.B.O.q
ADOREss EXISTING ROOF COVERING
PHONE � � \ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S TO BE REMOVED TO BE RETAINED
NAME—
ADDRESS
AME_
COTDYR&z P5 �d� �,���+ �x tr1 TYPE OF ROOF COVERING
EXISTING
PHONE V`-'N '\C�7 `-Y BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license is in full force and rl
effect. 'n
C ( WOOD SHIN LES
License Cl s y Lic.Number `�+ x
OTHER(SP I FIY
Data Contractor kV 2 2 1 ��JAI
OWNER-BUILDER DECLARATION PROPOSED U
I hereby affirm that I am exempt them the Contractor's License Lew 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 R ❑
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions (,{)/
of the Contractor's License Lew(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 aIle' PHALT SHINGLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant l
a civil penalty of not more than five hundred dollars($500).): 1!5
�� ES
1,as owner of the property,or my employees with wages as their sale compensation,will do ❑
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Proces-
sions Code:The Contractor's License Law does not apply to an owner of properly who builds or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not Intended or offered for sale.II,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.).
1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE LC.B.O.REPORT NO.
apply to on owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. .B 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
y Ilefiby affirm under penalty of perjury one of the following declaration:
have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building b
asp idad for by Section 3700 of the Labor Code,for the performance of the work for which this 3 0
permit is have
anIssued. 0 O Seismic r
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700's %
the Labor Code,for the performance of the work for which this permit is issued.My Worker's c•� �j�/ ��
Compensation Insur�an�c�e;carrier�and Policy
liicy number are: l\\ i Total (�
carrier ��� x^•� �"yi Policy No•wPERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCO /
(This section need not be completed it the permit is for one hundred dollars($100)or lass.)
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 workersCompensation Laws or Ceii- All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof 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
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply P Y with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have read this application and stale that the above information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and AI of Coverings to be classor better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
purposes. ` v Q 1
(We)agree to cavo,indemnify and keep harmless me City of Cupertino against liabilities. O�'
judgments,costs and expenses which may in any way accrue against said City in consequence SI NA U EAPP ICANT ATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: I ROGRES
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