99120011 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERAINIM
INSPECTION DIVISION PERMIT EXPIRATION
--REROOF PERMIT (408)777-3228 FERMI 180 EXPIRES IF WORK
IS NOT STWITHIARTED
'- 100 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
1 11!1OOL t , RESIDENTIAL X COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
M26
YES ❑ If yes-I understand that a Class A
NAME_{_L-1 root assembly is required.
NO ❑ Initial I.C.B.O.If
ADDRESS— EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS 0
CONTRACT R'
NAME � K 7 Tl OD(�6�G L- Y, ( 1� TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP �LZ �t+•Gs �'Coc.� .�5t2
EXISTING
PHONE C �� 9 Z� �"'� 7-Z ! BUILT-UP ROOF
CENSE
NUMBER HALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section 11 SHAKES El7000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect, /.JLT/01 S S ❑
License Class��Y�17a Lic.Number
Data--,% OWNER-BUILDER
-Contractor�i�TION G. OTHER(�ECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that am exempt from the Contractor's License Lew for the following reason.
(Sec.70315,Business and Professions Code: Any city or county which requires requires permit to a
construct, improve,demto file h.sigedstir any tementrthate,priortoile issuance,totalsohehaialhe BUILT-UP ROOF D
.I ad Contractor's
for such permit to file a signedstatement9(commencing
that he is licensed pursuant to the provisions
of Iha ss an Professions
rfLiconse Law)or that 9(commencing with Section 7000)of Division 3 0l the
Business and Professions Cade)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLE DEC ❑ 2
• exemption.Any ltyofolt more
fhan ioehundrbyanys($icentlora permit subjects the applicant to
a civil penalty o1 not mono than five hundred dollars($500).): WOOD SHAKES 1999
❑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 Profes.
sions Code:The Contractor's License Law does not apply to an owner of properly who builds or WOOD SHINGLES B ❑
improves thereon,and who does such work himself or through his own employees,provided that
J
such improvements are not Intended or offered for sale.It,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 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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&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: -714
O 1 have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, 5� Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
ued.
permit or Code, `�. Totalseismic
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of vi `� t 5
the Labor Code,for the performance of the work for which this permit is issued.My Worker's Total
Compensation Insurance carrier antl Policy number are: �� �
Carrier ��l Policy No.'JI
_.jIC11�pp
ddJi1nTPERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION it the pferelINSURANCE N.C.❑
(This section need not be completed if the permit is for one huntlr tlollam($100)or less.)
I certify that in the performance of the work for which Ihls,no
s issued.I sha11 not employ
any person in any men ar so as to become subject to the Worb Compe anon taws m tali- All roofs shall be inspected prior to any roofing material being
forma. /l fill installed. root is installed without first obtaining an
Date Applicant oIn I agree to rem ew materials for inspection.
NOTICE OAP ICANT: II,after making this Carr icale of Ex pti n,you should become A t understand and will om I With all In point
subject lot a Wo ere'Compensation provisions of the Labor Co e, must forthwith comply P P Y P
with such provisions or this permit shall b"deemed revoked. S Ufce r UI atIODS.
comfy that have read this application and state that the above ormoticn Is correct agree
tocomplywilh alltiryantl county ordinances and state laws reletingbbulldinpconstruction,en0 II rOOf CO rings tOb CI "Orbe er.
hereby authorize representatives of this city to enter upon the above-mentioned pro perry for in-
speclion purposes.
(We)agree to save,indemnity and keep harmless the Cily o/Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in Consequence SIGNATURE O APPLIC 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