00020161 PERMI
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
e WITHIN 1130 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING
ADDDDDRRREESSS) '1�/�'
f D '✓ ` ` `) RESIDENTIA COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
cit 1/I VES ❑ If yes s I understand ire a Class A
NAME \/CJV 1/r ` �I 1 1 l/V1 roof assembly is roquired.
�j ` •gyp ���r �^ n NO ❑ Initial I.C.B.O.W
ADDRESSk1 I^✓/— //,}�'��V'L/v l� y� • EXISTING ROOF COVERING
PHON ( V ^ NUMBER OF EXISTIN OVERINGS
CONTRACTOR'S
BE REMOVED TO BE RETAINED
NAME 11 , �V��' ` //� I q /� ,,, /�
ADDRESS TYPE OF ROOF ZVRIN
CITU 8 ZIP I
XI TING
PHONE BUILT-UP ROOF
NUMBER . I, ASPHALT SHINGLES ❑ 4
LICENSED CONTRACTORS DECLARATION /O
hereby inion that am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
]000)of Division 3 0l the Business end Professions Code,end my license is in full force and
effect' (//(J/" WOOD SHINGLES
License Cis Lie Number ❑
19
Date Contra cto :1 OTHER(SPECIFY)If ❑
OWNER-BUILDER DECLARATION ROPOSED
I hereby affirm that I am exempt from the Contractor's License Law a Ilawi g r n.
(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 ❑
applicant for such permit to fila a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section]000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES p
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($5001
I,as owner of the property,or my employees with wages as their sola compensation,will do WOOD SHAKES ❑
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 SHINGLES 1:1improves thereon,antl who does such work himself or through his own employees,provided that
suchimm
proveents are not intended or offered for sale.11,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 Code: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 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
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, 1pyla Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this / r�/`/ !\permit is issuetl. lico
1
`y'q�f'ave and will maintain Worker's Compensation Insurance,as required by Section 3700 of SQIBmID
th9 L%a ,Code,for the performance of thew for which this permit Is issued.My Worker's
Compens ion Insurance carr) tl Policy nu er are: -�I,L ^ Le'L Total
Carrier Policy No, , V( ^l�C/Y PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEM ION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ �1
(This section need not be completed if the permit is for one hundred dollars S1 00)or less.) / 3r ZQ ��
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 Call. All roofs shall be inspected prior to any roofing material being
fornix. installed. It 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 A licant understands and will co I Wlth all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp y
with such provisions or this permit shall be deemed revoked. source latlons'
I certify 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 state laws relating to building construction,and All of cc Brings to a lass r after.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- �]
spectmn purposes. Z
(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 SI_GNATUREOFAPPI 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