000200040
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PERMIT R—
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERM (Q ) 3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
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180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �7
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RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
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YES ❑ 11yes— I understand that a Class A
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NAME ' `^"'"^^r `—'� ✓" " —
roof assembly is required.
NO ❑ Initial I.C.B.O.k
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SO! �{
EXISTING ROOF COVERING
ADDRESS v�Q/YYIQ� /
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NUMBER OF EXISTING COVERINGS
PHONE
TO BE REMOVED TO BE RETAINED
CONTR'S
NAME
6 TYPE OF ROOF COVERING
ADDRESS '4i„ c�, _ %1 I 17— � r:, ��! f L
CITU 8 Z1p c7.lirt y�tl u.eL'a !'Z
EXISTING
PHONE% sod X913 -6373
BUILT-UP ROOF
LICENSE
NUMBER �FjZ 70 0
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I em licensed under provisions of Chapter y (commencing with Section
]OOO) of Division 3 of the Business and Professions Code, and r 9 license is in full lone and
WOOD SHAKES
effect.
C343 41 T`2
WOOD SHINGLES O
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License las Lic. Number
F�
0
3/01
OTHER(SPECIFY) ❑
Date Contractor
PROPOSED
OWNERBUILDER RATIO
I hereby affirm that I am exempt Iron the Contractors License Lawlor the following reason.
(Sec. 7031.5, Business and Professions Code: Any city or county which requires s permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the
BUILT-UP ROOF
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) 01 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
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a civil penalty of not more than live hundred dollars ($500).):
❑ as owner of the property, or my employees with wages as their sola compensation, will do
the work, and the structure Is not intended or offered for sale (Sec. 7044, Business and Profes-
sions Code: The Contractor's License Law does net apply to an owner of property who builds or
WOOD .SHAKES1,
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WOOD SHINGLES _.-- ❑iJ�
improves thereon, and who does such work himself or through his own employees, provided that
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such improvements are not intended or offered for sale. If, however, the building or improvement
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is soltlwithin one year of complotion, the owner -builder will have the burden of proving that he did
not build or Improve for purpose of sale.).
OTHER(SPECIFY)FEB i ter
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
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the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or improves thereon, and who contracts for such projectsf,�
with a contractor(s) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR IN$TiiLIL iTION SPECS/
❑ 1 am exempt under Sec. ,B 8 P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
O d
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 Worker's Compensation,
/
/
Building
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
tis issued.
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per
have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
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Seismic
LaborLa Code, for the performance of the work for which this permit is Issued. My Worker's
Total"
Compensation Ins ren carrio_r an icy umber are: Cp /
/�25
PERMIT AUTHORIZATION
DATE
Carrier G..�y 71 PolicyNo.S7/—LI/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed if the permit is for one hundred dollars (5100) or less.)
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' Comc, anon Lawa of tali-
All roofs shall be inspected prior to any roofing material being
fornix,
installed. If a roof is installed without first obtaining an
Date O / 60 Applicant
inspection, I agree to remove all new materials for inspection.
NOTI E CA CANT: II, alter making this Certifiy [e of Exemption, you should become
Applicant understands and will comply with all non point
PP P Y P
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith Comply
with such provisions or this permit shall be deemed revoked.
source regulations.
I certify that I have read this application and state that the above information is correct.I agree
be "or better.
to comply with all city and county ordinances and state laws relating to building construction, and
All roof coverin to cl s
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We) agree to save, indemnity and keep harmless Ne City of Cupertino against liabilities,
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judgments, costs and expenses which may in any way accrue against said City In consequence
SIGNATUR OF APPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY