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PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R"
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1BO DAYS OF PERMIT ISSUANCE OR
. IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
7S (9—i edlfls!t Vossorll RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME �� a,M4 x a 1 NO ❑ roof assembly is required Hal I.C.B.O.q
ADDRESS 715 —I PeG�,�,. ZIOSSDr-, EXISTING ROOF COVERING
PHONE bL.S •• Ol- [, NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
lass S 1 TO BE REMOVED I TO BE RETAINED
NAME ('�p��'- E n7( ziriliL
ADDRESS 1 _ / 1,' TYPE OF ROOF COVERING
CITY&zip ��I L. rjewt, aLl �ln Mme /Sp.g
EXISTING
PHONE /Y-"�L��`T�� BUILT-UP ROOF ❑
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES rLJl
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
effect. WOOD SHINGLES
License Class C LIC.Number
Data /'3'C;I0o0 Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
1 hereby affirm IneI am exempt fromthe Contractor's License Lew for the following reason. V
(Sec.70315,Business s and Professionss o
Code: Any city or county which requires a permit to
construct,altar,improve,to
a siorrepairanystructure,prior toits issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed r statement(commencing
he is licensed pursuant m the provisions
of the Contractor's License Lew(Chapter 9(commencing Section 7000)of Division 3 of the
Business and Professions Cede)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES -
aexemption.civil Any lty of oft more
Secthan
five hundred
by any elta*(licant for a permit sublecis the applicant to
a civil penalty of not more tern eve by employees
yees ($Soo).): WOOD SHAKES _
❑Las owner structure
i not i tended ayeeered wages(as Sec.their sole compensation,snPr ill le /� ❑~�
the work,and the structure is not intended ores net
for sale(Sea owner
of Business and Pmbs- �.Z
seer esthe ea,Contractor's License Lawdi self rthroughhapply to an s own ofproperty who builds or tA/QOD SHINGLES /.. /J
improves thereon,and who does such work edf oft or through his own employees,provided that /n ❑ j
such improvements are not intended or offered for sale.If.however,the en of pr or improvement ///// J/�
nsoldtbuild or
prove for purpose
sthe owner-builder will have the burden of proving that he tlid. OTHER(SPECIFY) V r/�f/
not build or improve for purpose of sale.).
❑i as tweer of the property,am exclusively contracting with licensed contractors to construct
the apply to
j an owner
of property
hantls or improv Code:The Contractor's Licosa Law does not PROVIDE LC.B.O;REPORT NO.
apply loanownerot property pursuant
the Contractor's License
and who contracts for such protects
with a contractor(s)licensed pursuant tome Contractor's License Law. PROVIDE MFGR.INSTALIATII�N'SP_ECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury one of the following declaration: _
I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, &7,3 I S Building
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this 1
parmilj ave antl. �� 3-aQD0 Seismic
C.La have and will maintain Worker's Compensation Insurance,as required i by Section 3700 s
the Labor Cotla,for the performance of the work for which this permli is issued.My Worker's
Compensation Insurance ckarrier��ntl.TPolicy number are: �v —06 Tota
rl
Carrier TQ. `y' `"� Policy No.Un-• C lPERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C❑
(This section need not be completed of the permit Is for one hundred dollars($100)or less.) oT' it — 3
I certify that in the performance of the work for which this permit is issued,I shall not employ V
any person in any manner so as to become Subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornia. installed. It a roof is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,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 doomed revoked. source regulations.
I certify that I have read this application and slate that the above information is correct I agree
to comply with all city and county ordinances and state laws relating to building constructor,and All roof coven s be Class" or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spathe)purposes. ` l 3o
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may on any way accrue against said City it,M.Sequence 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