R 5656 PERMIT R_ 5 6 5 6
CITY OF CUPERTINO NUMBER
APPLICATION FOR INSPECTION DIVISION'
PERMIT EXPIRWORK IS
N
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES O WORK IB ISSUANCE
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
' 190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
V/
C—r, RESIDENTIAL COMMERCIAL OTHER
OWNER'S 1 HAZARDOUS FIRE AREA
�{-a i1 _ �1te . _ VES ❑ If �s-1 understand that a Class A
NAME I• {/r MAw "✓M1t; - f assembly is required.
N Inifial I.C.B.O.#
ADDRES'00,cf VC/ C4- EXISTING ROOF COVERING
PHONE — I r UMBER OF EXISTING COVERINGS I
CONTRACTOR'S �// /J TO BE REMOVED---[—TO BE RETAINED
NAME &/e' , + /CEA r.�
ADDRESS (�1 't /�, f TYPE OF ROOF COVERING
CITY B ZIP_/_dSJ uL(/ rLc� h •� �1`GY1( _
EXISTING
PHONE 7 7 0r9q.3r�O BUILT-UP ROOF
LICENSE
NUMBER t� / T ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION t.7
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business end Professions Code,and my license Is In full force and
effect. WOOD SHINGLES
❑ {
License Claes�� b Lic.Number ,
Date L ja `� Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Profession.Code: Any city or county which requires a permit to
construcapplicnt,elter,improve,demto file signed any prior loIts i pursuant
enquires the BUILT-UP R00� ❑
applicant for such permit to file ah,or re statement that he Is Ilcensetlssuance,al the quireprovisionsthe
of the Contractor's License Lew(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 SHI ❑
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($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes-
aloneCode:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHINGLES C ❑
Improves thereon,and who does such work himself or through his own employees,provided that
such improvements era not Intended or offered for sale.If,however,the building or Improvement �►►
Is gold within one year of completion,the owner-bulkier will have the burden of proving that he did OTHER(SPECIFY) V7y
not build or improve for purpose of sale.).
01,as owner of the property,am exclusively contracting with licensed contractors to construct - ^ Ad+�
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. Zi(L7
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Data A L A I DATE VALUATION PERMIT FEE
' WORKER'S COMPENSATION DECLARATION
I hereby atlirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, r flI1RA '(I RL11gS1 Building
s IIYUV 2S F U �D
as provided for by Section 3700 of the Labor Cade,for the performance of the work for which this /
pu le Issued. cc rl Selsmic
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of CI Ur LUPEH rINO
th bar Code,for the performance of the work for which this permitr IeOfu�tlQ.MsWk$ra
Cc sensation Insurance carrier and Policy number are: v s� y� '2-7 Total
Carrier � ��-►`e� Policy Nolr&-37 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed 1f the permit Is for one hundred dollars j$100)or less.)
1 certify that In the performance of the work for which this permit Is Issued,I shall not emptoy
any person in any manner so as to became subject to the Workers'Compensation Laws of Ca11- All roofs sWdll be inspected prior to any r offing material being
totals. 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: 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 deemed revoked. Source regulations.
I certify that l have read this application and state that the above Information is correct.l agree
to comply with all city and county eminences and state laws relating to building construction,and All roof CO rings CaSS"Ca or be r.
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,costa and expenses which may In any way accrue against geld City in consequence
4/1
of the granting of this permit. SIGNATURE OF) DATE
PREINSPECTION: PLYWOOD: I 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