R-66146
•
APPLICATION FOR
REROOF PERMIT 31
DING ADDRESS p
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OWNER'S
NAME
ADDRESS
CITY & ZIP
CITY OF CUPERTINO PERMIT R_NUMBER 6 614
INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
PHONE
❑
LICENSE
//1 �)LP73/
NUMBER
((/
I hereby affirm that I em licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the BuW4ess and Professions Co e, and my license is In lull force and
effect COY aa /3
License Class Lic. Number
Date Contractor
OWNER -BUILDER DECLARATION
1 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
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
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).):
❑ 1, 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 property who builds or
Improves thereon, and who does such work himself or through his own employees, provided that
such Improvements are not intended or offered for sale. II, however, the building or Improvement
Is sold within one year of completion, the owner -builder will have the burden of proving that he did
not bulld 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 Contractors License Law does not
apply to an owner of property who builds or improves thereon, and who contracts for such projects
with a contractors) licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec. ,B & P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to sell -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.
❑ 1 have Qd will maintain Worker's Compensation Insurance, as required by Section 3700 of
the LOO.r for the pedormg ce of the work for which this permit Is Issued. My Worker's
Camp nse d I suronce carria(a d Policy number are/::���� / , {� n../n1
Carrier -k?ollfy No. ULq
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed it the permit Is for one hundred dollars ($100) 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' Compensation Laws of Cali.
fornla,
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shall be deemed revoked.
I certify that I have read this application and state that the above Information Is correct ) agree
to comply with all city and county ordinances and state laws relating to building construction, and
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 the City of Cupertino against liabilities,
judgments, costs and expenses which may In any way accrue against said City in consequence
PRE -INSPECTION:
\$:01.1
19��rdUI�]1rA
INSP. DATE 11NSP.
RESIDENTIALy COMMERCIAL OTHER
YES ❑ It yes — I understand that a Class A
roof assembly is required.
NO fT Initial._. I.C.B.O.If
NUMBER OF EXISTING COVERINGS
TO BE REMOVED / TO BE RETAINED O
TYPE OF ROOF COVERING
EXISTING
BUILT-UP ROOF
❑
ASPHALT SHINGLES
❑
WOOD SHAKES
[L}�
WOOD SHINGLES
❑
OTHER (SPECIFY) ❑
ROOF to o -
JUNE-1ggg
WOOD SHINGLES
OTHER (SPECIFY) ❑
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
VALUATION PERMIT FEE
Buildinga'V. 00
Seismic . _/Q
Total 01 -v L
PERMIT AUTHORIZATION I DATE
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
source regulations.
All �roof covert o be class Vor better. (0/ /� 4 �iY �.0/X tL::*
`3T`U1�1ATOTIE i APPLICANT DATE
FINAL:
DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY