99070066 7_7 % 6 - zZ o 0 7 oa
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN ISO DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /f/., (,[.
/L,)/<// � 1 % e�/ ` ' RESIDENTII COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
) t _ VES E] II yeaI understand thatClass A
I
NAME '�-�/J roof assembly Is required..
NO ❑ Initial I.C.B.O.W
ADDRESS S G vv% y EXISTING ROOF COVERING
PHONE rl2ii
_ NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S -
NAME - S - TO BE REMOVED�TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP r� EXISTING
PHONE OI BUILT-UP ROOF ❑
NUMBER ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Coda,and my license Is In full force and
effect, (��(//y WOOD SHINGLES ❑
License Class l° 2 LIP.Number b=/ 5 511
—Z�—OIy LMAY/A�.i%ezw2c' ctr. OTHER(SPECIFY)
Dao DBUILDE !,\
OWNER-the Contractor's
License
PROPOSED \\
hereby affirm that am exempt fromns Co e: Any city License Law for the following reason.
(Sec.7ct,alt Business and Professions or res Cotle: Any city or county which requires a permit to y D
construct,altar,improve,demolish,signed
or repair any structure,prior o its Issuance,also requires the BUILT-UP ROOF I �[ 2
applicant for such permit to flaw a signed statement that he is licensed pursuant to the provisions 1f10(]
of the Contractor's License Lew(Chapter h(commencing with Section 7000)of Division 3 0t,the IJJJ
Business and violation
of Code)or that he is exempt therefrom and the bass for the aant to ASPHALT SHINGLES ❑
exemption.pen.Any violation of Section hundred
by any applicant for a permit subjects the applicant to
a civil penalty of not more than five huneree tlollera($500).p WOOD SHAKES 13
C]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-
sions Code:The Contractor's License Lew does not apply to an owner of property who builds or1/1100D SHINGLES
improves thereon,and who does such work himself or through his own employees,provided that El
such improvements are not Intended or offered for safe.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 Coda: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 contractors)licensed pursuant to the Contractor's License Levi. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B a 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 os following declarstlon:
❑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 a issued. SBIS C 1 t
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the Labor Code,for the performance of the work for which this permit Is Issued.My Workers /��00 Tota I �
Com enation Insurance carrier and Polic number are: n L�'�v
Carrier V1 VIOV� Z Policy Nel�`IF�-=Y PERMIT AUTHORIZATION ATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE �—
(This section need not be completed if the permit Is for one hundred dollars S1 00)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 Can. All roofs shall be inspected prior to any roofing material being
fornia. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOT CE become
subject o theOWoP era Compensation provislonafter makinls o Certificate
Labor Code,you of mustuo thwiitth comply Applicant understands and will comply with all non point
with such provisions or this permit shalGbe deemed revoked. Source regulations.
1 cetlfy 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 stale laws relating o building construction,and All roof co ri gs to be class" or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In.
sp purposes.
(We) ( CyCA 7-74-'(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 SIGNATURE OF APPLICAW 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY