R-67140
0
0
12���APPLICATION FOR c9.!F c9.!cUPERTINO
INSPECTION DIVISION
REROOF PERMIT 40 22
10,2,414 Dr
NUMB PERMIT R- 6 714
PERMIT EXPIRES IF V
WITHIN 190 DAYS OF
COMMERCIAL OTHER
YES ❑ If yes — I understand that a Class A
NAME f assembly is required.
�},� 7 N Initjal_
/"l
f r V-LP,k� EXISTING ROOF C(
ADDRESS
CITY & ZIP
PHONE
K
BUILT-UP ROOF
CENSE
ASPHALT SHINGLES
❑
NUMBER
(7
OTHER (SPECIFY)
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
]000) of Division 3 of the Business and Professions Cade, and my license is in full force and
effect.
License Class r. Lic. Number
%
Date Contractor
OWNERBUILDER DECLARATION EA Z2 C
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
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractors License Law (Chapter 9 (commencing with Section ]000) 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 ]031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars ($501
❑ 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 Proles.
some 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. 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.).
❑ 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
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.
01 am exempt under Sec. ,B 8 P. C. for this mas4w
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration:
[JI have and will maintain a Certificate of Consent to self -insure for Worker's Came.nsa
as provided for by Section 3]00 of the Labor Code, for the pedormance of the work for whic 1 5
permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as requiretl by Section 3] of
the Labor Code, for the performance of the work lot which this permit is issuetl. My Wo k¢�s
Compensation Insurancecarrier and Polic number are: 106-
B
Carrier r C%^ - Policy No. L 02.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[]
(This section need not be completed if the permit is for one hundred dollars ($100) or less.)
I certify that in the performance o1 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' Componsation Laws of Cali.
fornia.
Data 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. I 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 lot 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
of the gaiting of this permit.
I.C.B.O.
NUMBER OF EXISTING COVERINGS I
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
EXISTING
K
BUILT-UP ROOF
❑
ASPHALT SHINGLES
❑
WOOD SHAKES
WOOD SHINGLES
OTHER (SPECIFY)
PROPOSED
BUILT-UP ROOF
ASPHALT SHINGLES
K
WOOD SHAKES
❑
WOOD SHINGLES
❑
OTHER (SPECIFY)
❑
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
ATIO DAT
VALUATION
PERMIT FEE
Building ��—
21 1999
7 / %S dO
Seismic /15 -
Total 15 S
- "'T el IT
ORIZATION
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 en be cla "C" or better.
/Oo � oyd 7-7V
SIGNATURE OF APPLICANT DATE
PRE -INSPECTION: PLYWDATE INSP. DATE
IN-PRDATE INSP OGRESS: DATE
TEAR OFF INSPECTION: BATTENS: I FINAL:
INSP. DATE I INSP.
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICECOPY