99120010 L-_,5 o WS qql zoo ✓ o
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBS
INSPECTION DIVISION PERMIT E%PI ATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
L WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS f
C� RESIDENTIAL K COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�� W V J N YES ❑ It yess understandreq that a Class A
NAME C L� ` .� roof assembly is required.
NO ❑ Initial I.C.B.O.H
ADDRESS J!C!p7a cCq�LLtlt�tnSOarA �� EXISTING ROOF COVERING
PHONE C p) ( NUMBER OF EXISTING COVERINGS _21 _
CONTRACTOR'S
NAME 5(�-IASL irC Y TO BE REMOVED 70 BE RETAINED
ADDRESS �7 LL TYPE OF ROOF COVERING
CITY sZIP �ii�77 'f11NLS �tst1J �` `t� ILl EXISTING
PHONEC T.1?Q� 171 ' 17 '/ BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect. a WOOD SHINGLES ❑
License Class �Zd Uc.Number 9C
Date—Q M Contractor O OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION p SED
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 P 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)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASP I LES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to D
a civil penalty of not more than live hundred dollars($50(1 W O1�K 0
I,as owner of the property,or my employees with wages as their sole compensation,will do tr��,�
the work,and the structure is not intended fer offered for sate(Sec.7044,Business and Profes. N(?
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WCCD S NGLE'f� Q� 1999
Improves thereon,and who does such work himself or through his own employees,provided that `.1
such improvements are not intended or offered for safe.If,however,the building or improvement
!as oM within one year of completion,the owner-builder will have the burden of proving mat he did OTHER(SPECIFY)
not build or improve for purpose of sale.). bbb 0
❑I,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.REPO \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 Contractor's License Law. PROVIDE MFGR.INSTALLA ON SPECS.
❑I am exempt under Sec. .B 8 P.C.for this reason x
0�iy
Owner Data APPLICATION DATE VALUATI N PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: 6/.S ¢ �� t S
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, 17, (i / 1••J Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
u r�D
I neveve andend will maintain Workers Compensation Insurance,as required by Section 3700 of -1 S215mIC y^
the Labor Code,for the performance of the work for which this permit is issued.My Worker's Total
Compensation Insurance carrier and Policy number are: 1.,'1 A �y'J
Carrier Polity No.WC� Gs PERMIT AUTHORIZATION DATE
CERTIFICATE OF (EMPTION FROM WORKERS'
COMPENSA ION INSURANCE N C.]
(This section need not be completed if the coral
ora Is for one n1 dollars($100)or less.) �� 2 - 2
I certify that in the performance of the work for which this it shall not employ r
any person in any manner so as to become subject to the ars' maps aalion Lawa of
calm All roofs shall be inspected prior to any roofing material being
forma. qy installed. If a roof is installed without first obtaining an
Date _ 7 Applicant ^,.1
spection,I agree to remove all new materials for inspection.
NOTICE AP (CANT: It,after making this Certilica a of Ext%ra ion,you should became A icant understa d will comply with all non point
subject to the Workers'Compensation provisions of me Labor Code, muss forthwith comply p
with such provisions or this permit shall be deemed revoked. SOU a regulation .
I certify that I have read this application and state that the above information is CorreCL agree �J
to comply with all city and county ordinances end state laws relating to building cmnsVuction,antl All rO iC efingS tO beC SS or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in. iJ
spection purposes. + at
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, -Z
judgments,costs and expenses which may In any way accrue against said City Ia consequence IGNATURE OF APP (CANT 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