99110143 (lUl
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION WE WATION
REROOF PERMIT (408)777-3226 PER MIT EXPIRES IF WORK ISNOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM UST CALLED INSPECTION.
BUILDING ADDRESS Zr
l
Q RESIDENTIAL COMMERCIAL OTHER
—
MF's HAZARDOUS FIRE AREA
�� YES ❑ It yes-I understand that a Class A
NAME �,( U 5�.2/ real assembly is required.
Q NO ❑ Initial I.C. LO.N
ADDREss_1�9�� ��r o EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRAC OR'-S
/�(1 SC6!n TO BE REMOVED
CP
NAME S
TO BE RETAINED
NAME
�1 g 1 TYPE OF ROOF COVERING
ADDRESCITY&ZIP-ar�M �i g- J!� Scay\ Le- Cl4
f'' EXISTING
PHONE (yOY� yy�—D�oy BUILT-UP ROOF ❑
LICENSE
NUMBER Srf'7,3 ASPHALT SHINGLES ❑
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 lorce and
affect' /' WOOD SHINGLES
License Class (-3q Q Lic.Number S 5 ` ;Z 3IL+ ❑
Data
11-212-99 Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that 1 am exempt from the Contractor's License Law for the 11 g r
(Sec.7031.5.Business and Professions Code: Any city or county which requires a permit to ❑
construct,alter,improve,demolish,or repair any structure,poor to its issuance,also requires the BUILT-UP ROOF�LLLlrrrl---!CLCLCLII U�`�
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 !z �0V III---III no
. Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHIN �JJ
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to u 'y
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKE
I]I,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHIN L'ES
improves thereon,and who does such work himself or through his own employees,provided that
such improvements are not intended or offered for sale.IL however,the building or improvement
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) /p
not build or improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors 10 construct
the project(Sec.7044,Business and Professions Code:The Contractofs License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
hereby affirm under Penna of perjury one ofthe following declaration: I
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, BW Iding
00 of the L
as provided for by Section 37abor Code.IOr the performance of the work for which this ---kms
permit is issued. SeiB IC 1
ILa`or and will maintain Worker's Compensation Insurance,as required by Section 3700of's
the labor Code,for the performance of the work for which this permit is issued.My Worker's �� OD
Campers Insurance cnrri end Polity Q\umber ere: cv-� ��z-9 506 Tota ✓
Carrier L'+$'La'�crQ� rO c22, Policy No. � ��� Dr�L7 PERMIT AUTHORIZATION DATE
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.) Z 2
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 Worl a Compensation Laws of Can- All roofs shall be inspected prior to any roofing material being
brnia. installed. If a roof is installed without first obtaining an
Date-114--�f9 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this C99 tic xobpbon,yo mould become y Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions olthe ra r Cotle,you mus onhwith cora PP P Y P
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that l 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 construction,and All roof coverings to be las "or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for 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 SIGN URE AP - ,4th DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN, ROGRESS:
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