00020012 In
PERMIT
APPLICATION FOR CITY OF.CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 150 DAYS OF PERMIT ISSUANCE OR
150 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS .�K•� 1 /y� `X/
Z`02- IV O 1 ` C L 1 Lk� RESIDENTIAL � l COMMERCIAL OTHER
OWNER'S / ,/1-Iunderstand
HAZARDOUS FIRE AREA
NAME AAIJE I_611f VES ❑ met
tisretheta Class
roofs—Iassembly that
•� NO j Initial- I.C.B.O.W
ADDRESS��II 4)2b 0 Al01611" ILAU �,1.1.Fit 41) EXISTING ROOF COVERING
PHONE "tom o— 8'177 -7339 NUMBER OF EXISTING COVERINGS 1
CONTRACTOR'S .' '^ TO BE REMOVED 1 TO BE RETAINED
NAME
ADDRESSTYPE OF ROOF L L f q ql
NG
CITY 8 ZII�P.�y�")(x� q l, W L EXISTING
PHONE a""� 1 ��
BUILT-UP ROOF
LICENSE �1
NUMBER ` ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION X
hereby filum that em Business
under provisions of Chapter 5(commencing In with Section WOOD SHAKES
7000)of Divlalon 3 0l the Buelneee entl Professions Code,and my license le In lull force and "
enact' WOOD SHINGLES E]License Cis viC 3� Llc.Number _72-1511
Date "l10b Contractor IL OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter.improve.demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
fthapplicant for such permit to flaw a signed statement that g with
Section
licensed p 000)of to the provisions the
of the Contractor's License Law(Chapter 5(commencing with Sectlon 7000)of Division 3 of the
Business and violatalons Code)or that he Is exempt therefrom and the bade for the alleged ASPHALT SHINGLES ❑
exemppen.Any violation of Section hundred
by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollen(h wag): WOOD SHAKES
❑I,es ownerofthe property,or tmy ededoroadwith wages as their sole compensation,will do
the work,and the structure Is not Intended ores not for sale n owner Of,rephase entl Proles-
imprCode: The,anirdcto d License Law does not apply toansonar employees,
whobuildsWOOD SHINGLES
improves thereon,and'who does such work himself or through his own employees,provided that ❑
such improvements are not Intended Or ownetl for idle.If,however,the en of pr or Improvement
Is notsold bullwithinor
year of for purpose
sthe ownarvbulltler will have the burden of proving that he tlfo OTHER(SPECIFY) ❑
not build dor Improve ler purpose al self.).
❑I,as owner of the property,andexclusively contracting with ntrneatl contracture to constructesnot
the project(Sec.70Aa,perty Business hentlsorImprovCode:TheContractor'sLicenseLawdoesnot PROVIDE LC.B.O.REPORT NO.
apply to c en owner of property who balite or Improves thereon,and ono contracts for such projects
with a am exempt
Index Se pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt untler Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty Of perjury one of the following declaration:
❑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 is Issued. II` 6 V� Seismic
Nfiehave and will maintain Worker's Compensation Insurance,as required by Section 3700 of
06 L Or Cotle,for the performance of the work for which this permit Is Issued.My Workers Q
.Compensation Insurance carrier entl Policy number are: / I Tota/7 Z
carrier PRZTI�- Policy Now 2000y 1155-
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.) /L�2-0 O v
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.
NOTICE TO APPLICANT: It,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
with such provisions or this permit shell be deemed revoked. source regulations.
certify that I have read this application and state that the above Information Is corract.l agree K2n
to comply with all city and counfyortllnancesantl state lewd relating to Oulltlinp construct coverings t0 be class" rbetter. ZI'L, Ldr1�
hereby authorize representatives OI this city to enter upon the above-mentloneo proper for Im `�
apecllon purposes.
(We)agree s save.expenses
and keep harmless wad the City ai Cupertino against Illlles.
judgments,costs entl permit. a which may In any way accrue against weld City In conseg0enec OF 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY