99120009 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
Tr48 of ii � RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
.� YES ❑ II yes—I understand that a Class A
NAME as C w OCiji l .S roof assembly is required.
p4 NO ❑ Inifal I.C.B.O.q
ADDRESS I L !ZA_ e0LW LnoTimei �i- EXISTING ROOF COVERING
PHONE e 0-g r NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME Olt C.._ -:g L
ADDRESS 11 _ Q��� —� TYPE OF ROOF COVERING
CITY 8 ZIP '[ W _(�I-1�
\ EXISTING
PHONE � �,) !?71-1-777 BUILT-UP ROOFLICENSE
�.
NUMBER ASPHALT SHIN LES El
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD ❑
7000)of Division 3 of the Business and Professions Code,and my license is in full lorce and
effect. //'�Q S—q WOOD �T- ❑
License Class' =IL'— Lic.Number 50� c `n.p
_/Z/ate 5{tuIljl �1 P�ua ` OTHER(SPE IF% ❑
Date Contractor
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm Ines am exempt from the Contractor's or coup Lew is the following reason. D //v
(Sec.]0315,Business and Professions Code: Any city or county which requires a permit to '/"•�L\l
con sbunLalter,Improve,to file signedrepair any statementrthate,prior toils issuance,to
he provisions
of
BUILT-UP ROOF
applicant for such permit to fife a signed statement that he is licensed pursuant io the provisions D
of the Contractor's License Low(Chapter 9(commencing with Section]000)of Division 3 of theDE
Business and Professions Code)or that heby
exempt therefrom and the basis for the alleged ASPHALT SHINGLES 2 1999
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to -
a civil penalty a not more than five hundred dollars(h wag): WOOD SHAKES 1,as ownerofthe property,or tmy eemployeeswith wages astheir sole compensation,will
s- By
❑
she work,and the ontr cto Is not intended ores not for sale(Sec.7044,Business and wilds or
Profes-
sions Code:The Contractor's License lawtliself apply to or
his
employers,who
rovidedsor WOOD SHINGLES �—
improves
thereon,and who
does nsuch work himself or through his own employees,provitletl that
such improvements are not completion,
leb n,the
offered for safe.It,however,the en of pr vi improvement
I.Said bull or
year of for purpose
s Iha ownerbulltlerwill have the burden of proving that he Oitl OTHER (SPECIFY) ❑
not build or improve for purpose of sale.).
I,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 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 contractions)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
I]1 am exempt under Sec. ,B&P.C.for this reason
Dan., Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration: S 00Buildin g
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, `��
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /
permit is issued. $elsmi
I have and will maintain Workers Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit is issued.My Worker's
Compensatio Insurance carrier and Policy number are: Total
Carrier ` ��'r PolicyNo.wa a���� PERMIT AUTHORIZATION DATE
•
CERTIFICATE OF EMPTION FROM WORKERS'
COMPENS IONINSURANCE N.C.❑
(This section need not be completed II the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this per issued,I shall not employ
any person in any manner so as to become subject to the W CompensymPikliaws of Cali. All roofs shall be inspected prior to any roofing material being
fornia. �qQ installed. If a roof is installed without first obtaining an
Date 1� do Applicant pection,I agree to remove all new materials for inspection.
NOTICE T APPLICANT. If,atter making[his to of Exemption, should become 6c t understand will comply with all non point
subject to the Workers'Compensation provisions of the Labor Cade,you m forthwith comply p p y
with such provisions or this permit shall be deemed revoked. urce gulations.
I certify that I have read this application and slate that the above information is correct.I agree
to re y ly with authorize rep and se county ordinances and ter upon
the
bove- anti ned property
and Ill f OVerin s to
b Cl er.
hereby authorise representatives of this city to anter upon the above-mentionatl property for in.
spectlon purposes. �� -9q
(We)agree to save,indemnify and keep harmless the City ai Cupertino against liabilities. -99
ofthe gran costs and expenses which may in any way accrue against said City in consequence SIGNATURE 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY