99110126 3 6 3 00.T- T1 // C/ Z (o
PERMI
APPLICATION FOR CITY OF CUPERTINO NU
MBE
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 /''
70(o O Iv L oo 54 RESIDENTIAL COMMERCIAL OTHER—
OWNER'S
THEROWN R'S HAZARDOUS FIRE AREA
WAS I kxod � L c VES ❑ to ofa s I assembly
is req that a Class A
NAME T U P 1� roof assernby is requiretl.
QO vhh [ NO ❑ Initial I.C.B.O.H
ADDRESS � l` 1�Q Sf EXISTING ROOF COVERING
PHONE v --W.-2, NUMBER OF EXISTING CO RINGS
CONTRACTOR'S y1,�- I(/� //—'^, ^/ G �'- ,V
NAMESe c r .�t ' �/ 1'QD ' `t'1"l 5V_5 :CAS TO BE REMOVED TO BE RETAINED
ADDRESS ) o w n] -I) Z TYPE OF ROOF COVERING
CITYB/z/IP '� ` EXISTING
PHONE CJ - BUILT-UP$RF
LICENSE
NUMBER � D / ASPHGLESLICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed untler provisions of Chapter 9(commencing with Section WOODS ❑7000)of Division 3 al the Business antl Professions Code,antl my license is in full force antl
effect / WOOD SLicen+seefClassq���� +�-_ Lic.Number�O�17 ❑Data1`_3f_Q) Contracter.7��. rOTHER( � ❑
OWNER-BUILDER DECLARATION PROPOSED �b
I hereby affirm that I am exempt from the Contractor's License Law 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 ROOF
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of tha 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 five hundred dollars($500).): WOOD SHADES
I,as owner of the property,or my employees with wages as their sole compensation,will do W ❑
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes.
hors Code:The Contractor's License Law does not or through
his
own employers,who
rovidedtat WOOD SHINGLES "ALLATIONSPECS.___�
improves thereon,and who does such work himself or through his own employees,provided that suchd withi oneyements arenot plebe ,oro fferedforsale.IL have the thebuilding enofproiimprovementnot buldorimneye for purpose or sthe Owner-builderwill have the burtlen of proving that he did OTHER(SPECIFY)not build or imprme for purpose of sale.).❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sac.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.Rapply to an owner of property who builds or improves thereon,antl who contracts for such projects
with a Conbactorls)licensed pursuant to the Contractor's License Law. PROVIDEMFGR.IN1 am exempt under Sec. B 8 P.C.far this reasonRif
OwnerDate
WORKER'S COMPENSATION DECLARATION APPLICATION DATE ALUATfON— PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
1/ 9
❑I have and will maintain a Certificate of Consent to self-insure mor Worker's Compensation, I t— ,�— ( L( J O Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this f
permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
the Labor Cotle,for the performance of the war lar which this permit is issued.My Workers Z7 (S
Compen ion Insurance car ier antl Itchy no are: 06327-6Total /Q__,0
carrier Policy No PERMIT AUTHORIZATION DATE
CERTIFICATEOFEXEM ION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed if the Ill for ane huntly tl tlolla ($100)or less.)
certify that in the performance of thew k for ich shi ermi fs issuetl shall nate ploy
any person in any manner so as to th subject a the rkers"compgp a ion Laws of all. All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
DtiIg-9�' Avp;;ean inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: ll,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non OmI
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit shall be deemed revoked. rce regulations
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 said laws relating to building construction,and All r I Coverings o b lass' or better.
hereby authorize representatives of this city to enter upon the above-mentioned property far in-
Boeotian purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence S ATURE OF APP ICANT 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