R-66160
•
APPLICATION FOR CITY OF CUPERTINO
REROOF PERMIT x-33 N (408)PECT7 DIVISION
(408)777.3228
BUILDING ADDRESS
l0/7b'�al new�
NUMBER R- 66 6
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
RESIDENTIAL COMMERCIAL OTHER
OWNER'S rIALArTUUUa FIKI
YES ❑ It yes —1 understand that a Class A
NAME 4 roof assembly is required.
�+ ,,,• ' NO ElInitial_
�/ EXISTING ROOF C(
NAME_
ADDRESS
CITY & ZIP
PHONE
LICENSED CONTRACTORS DECIARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license Is In Iul force and
enact.(//�j�
License Class 6,3 Llc. Number M
Data Contractor
OWNER -BUILDER DECLARATION
I hereby effirm that I am exempt from the Contractor's License Lew 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 (S5W).):
E)1, as owner of the property, or my employees with wages as their sale compensation, will do
the work, and the structure Is not intended or offered for eels (Sec. 7044, Business and Profes-
sions Code: The Contractors 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, provltletl that
such Improvements are not Intended or offered for sale. If, 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 build or Improve for purpose of sale.).
❑ 1, as owner of the property, em exclusively contracting with licensed contractors to construct
the project (Sec. 7044, Business and Professions Code: The ContraMor's License Lew does not
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.
❑ I am exempt under Sec. .B 8 P. C. for thls 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 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.
I] 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of
the Labor Co for Lha perfor enc. of the work for which this permit Is Issued. My Workers
Comp sail Ipsurence ce . na Policy number are: a
^� Grc1Z— ?fly
Cerrl Icy
IV CERTIFICATE WORKERS'
OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[]
(This section need not be completed If the permit Is for one hundred dollars ($1 g0) 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.
forma.
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 1 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, 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
PLYWOOD:
INSP. DATE ( INSP.
TEAR OFF INSPECTION: BATTENS:
INSP.
NUMBER OF EXISTING COVERINGS
TO BE
TO BE RETAINED
EXISTING
BUILT-UP ROOF
❑
ASPHALT SHINGLES
❑
WOOD SHAKES
Building
,, P40D SHINGLES
❑
(SPECIFY)
BUILT- F JUN t6 1999
ASPHALT S
WOOD SHAKES
WOOD SHINGLES ❑
OTHER (SPECIFY) ❑
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
J
APPLICATION DATE1
VALUATION
I PERMIITT,FVE�E��J
Building
'/^
/Q/`YV3•00
Seismic
_
Total
}� PERMIT AUTHORIZATION I DATE I
e Ir- 16 •-/6 --
All roofs shall be inspected prior to any roofing material being
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 covDARas to he class or better.
940NATUREOF APPLICANT DATE
IN -PROGRESS:
911210111111
DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY