99100115 r3 S-2 q !o C)
PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER
•fir 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
1 ` �Q RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ Ifyes s Imblyi req Ihat. Class
NAME \ \�.lJ roofassembly is required.
that
-�{ n NO ❑ Initial I.C.B.O.k
ADDRESS `Q ,t ^ EXISTING ROOF COVERING
`PHONE 1 + _ z.+'�W `�/ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
y
NAME 11_r,J Y� �y.L \���,,\it(`-\ t C TO BE REMOVED TO BE RETAINED
ADDRESS1y\� `"\_ �� C'� � TYPE OF ROOF COVERING
CITY 8 ZIP ¢ � �1V4AX�
EXISTING
PHONE `a"1—��G`�`� BUILT-UP ROOF ❑
CENSE
NUMBER a�jO�J ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I 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.
rn� (215 -/` WOOD SHINGLES ❑
License Class V `-^� Lic Number v
OTHER(SPECIF ----fl/ \` \
Delo S Contractor u t \
OW from the
Contractor's
RATION PROPOSED t' U
I hereby affirm that am exempt from the e: Anyrcity License Law for the following reason.
(Sec.7ct.alt Business and Professions Code: Any city or county which requires a permit e 1 y(1
construct,eller,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UPR ( lyl xY (j 1"
applicantfor such permit N fila a signed statement that he is licensed pursuant to the provisions I J
of the Contractor's License Low(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Coco))or or that
he is exempt therefrom and the basis for p icant to ASPHALT SH NGL O
azemppen.Any ltyofolt more)Section h031.5 undred anyapplicant($50t): apermit subjects the applicant to
a civil penalty of not more than live by employees
yeesdollars with
wag.): WOOD SHAKES By
❑I,as owner of tru properly,or to employees with wages as their sole compensation,will s-
the work,and the structure is net intended or offered for sale(Sec.7044,Business and builds
o-
improvns improves
The,an who
License Lawdoes not apply ough hOwner e property es,who rovide that WOOD SHINGLES ❑
improves thereon,and who tloes such work himself or through his own employees,improvement that
such improvementsaren01 intended or offered for sale, ill however,the en of pr or improvement
ntbuild sold or
prove for purpose
stheowner-builderwill have the burden of proving Nathodid 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 tloes not PROVIDE LC.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a confiscate)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑t am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
Cl I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this _
permit or Code, .may Total Seismic❑I have and will maintain Worker's Compensation Insurance,as inquired by Section 3700 of �\1\1/./71[
the Labor Code,for the performance of rhe work for which this permit is issued.My Worker's Total I
Compensation In/s^uyran/cue carrier/7andnPolicy number ere:
carder "` `"�,`1/ Policy No. 3 O 7 P .(-IORIZATION DATE
CERTIFICATE EXEMPTION FROM WORK-5—
COMPENSATION INSURANCE
This section need not be completed if the permit is for one hundred dollars($1(2or less.)
certify that in the performance of the work for which this permit is issued,Ishall noI employ
any person in any manner so as to became subject to the Workers'Compensation Laws of Cali- A s e Ins nor to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: IL after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y p
with such provisions or this permit shall be deemed revoked. source re Ons.
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,antlAll Of CO O clas 'or better.
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 l6RE OF APPLICANT DATE
01 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