R-67036
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l0 PERMIT 6703 7 O 3
APPLICATION FOR CITY OF CUPERTINO NUMBER R- U
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
/v z -70 L),•-,
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
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YES ❑ Ifyes Iunderstandthat. Class
that
NAME 142-1111 Q a-[�C "'
s
of assembly is required.
NO=f Inthal I.C.B.O. A
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EXISTING ROOF COVERING
ADDRESS l
C
NUMBER OF EXISTING COVERINGS
PHONE
I�
CONTRACTOR
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS VIP
TYPE OF ROOF COVERING
CITY&ZIP
EXISTING
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C`7`",, 1
PHONE 3(o2—
BUILT-UP ROOF ❑
LICENSE
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NUMBER la
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES 717000)
of Division 3 of the Business and Professions Code, and my license is in full force and
effect (/]� /n :Z
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WOOD SHINGLES
11Date
License Class v/ Lid. Number
%—l�p—��
OTHER (SPECIFY)
Contractor
PROPOSED
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors 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
BUILT-UP 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
ASPHALT SHINGLES
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:
WOOD SHAKES
❑ 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 Profes-
sionsCode: The Contractor's License Law does not apply toanowner ofproperty who builds or
WOOD SHINGLES ❑
improves thereon, and who does such work himself or through his Own employees, provided thet
such improvements are not intended or offered for sale. It, however, the building or improvement
is sold within one year of completion, the owner -builder will have the burden of proving that he did
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 Contractor's 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 contractor(s) licensed pursuant to the Contractor's License Law.
E MFGR. INSTALLATION SPECS.
❑ em exempt under Sec. ,B'8 P. C. for this reason
Owner Date
AP ON bATEPALLIATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION D
J UL 2 1 n n
�� a.
Building /
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
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permit is issued.
C]I have and will maintain Worker's Compensation Insurance. as required by Section 3]00 o
the Labor Code, for the performance of the work for which this permit is issued. My Worker' 13Y
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Compensation Insurance carrier and Policy number are:
Total
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Carrier I �� Policy No.wz ztzfe —
PERMITAUT
RATION
DATE
VV CERTIFIC�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 of the work for which this permit is issued I shall not employ
All roofs shall be inspected prior to any roofing material being
any person in any manner so as to become subject to the workers' Compensation Laws o1 Call-
forms.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, after making this Certificate of Exemption, you Should become
Applicant understands and will comply with all non point
P Y P
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shall be deemed revoked.
source regulations.
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
All Over tO2bcl s"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
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sP purposes.
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(We) agree save, indemnify and keep harmless the City of Cupertino against liabilities.
(We)
-7
judgments, costs and expenses which may in any way accrue against said City in consequence
judgments, s
SIGNATUR 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY