000400300
PE
APPLICATION FOR CITY OF CUPERTINO NUMBIEF
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
1W DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS 1
C�
lie 3S,5 PA, _r
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
,/understand
� CA
SES ❑ I
uire aClassA
NAME—" • 1S W I
bact required
roofs—IunIsar cored.
assembly is
NO ❑ Initial I.C.B.O. #
3 �K S; C,
EXISTING ROOF COVERING
ADDRESS 10 Iva rc r ¢4)1
3S - IS }�
NUMBER OF EXISTING COVERINGS
PHONE
It
CONTRACTO 'S
//J
TO BE REMOVED TO BE RETAINED flil^lw 12
NAME Q) SS Cl N o P /\00 (-1 yC
_
TYPE OF ROOF COVERING
ADDRESS/_
zz9� 41 l�
CITY &ZIP � HGO )I., l6atAl.e- C ill,,- RS I zC'
EXISTING
PHONE CQOtr) y+1? -QG 93
BUILT-UP ROOF
LICENSE
NUMBER 1��of'35
ASPHALT SHINGLES
O/
0
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES X O
7000) of Division 3 of the Business and Professions Code, and my license is in lull force and
effect.
WOOD SHINGLES ❑
(��f c
License Class ` Lia Number
(3 O
(SPECIFY) ❑
Date — ContractorOTHER
OWNER -BUILDER D et N
PROPOSED
I hereby affirm that I am exempt from the Contractor's Ucen aw 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 ❑
applicant for such permit to lila a signed statement that he is Iicensod pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the
Business and Professions Code) or that no is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES ❑
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)0:
WOOD SHAKES ❑
❑ 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-
sionsCode: The Contractor's License Law does not apply to an owner of property who builds or
WOOD SHINGLES El
thereon, and who does such work himself or through his own employees, provided that
such improvcments are net Intended or offered for sale. If, however, the building or Improvement
is sold within one year of completion, the owner -builder wilt have the burden of proving that he didOTHER
(SPECIFY) ❑ 641 r
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 Cotle: The Contractor's License Law does not
Q'
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.
[:jI 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 penalty of perjury one of the following declaration:
❑ I have and will maintain a Certificate of Consent to sell -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
per us issued.
Seismic
I have and will malmaln Worker's Compensation Insurance, as required by Section 3700 of
the L bar Code, for the performance of the work for which this permit is issued. My Worker's
Compenss�ation Insurance carrier d Poli nub\^bar are:
% e�-
CiQ�
Total
Carriar7 `m a..n•! vL �Pr0 C"y'1I Policy No. SMQAO Y �0O
PERMITAUTHORIZADTION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
M
COMPENSATION INSURANCE N.C.C]
(This section need not be completed if the permit is for one hundred dollars ($100) or less.)
dorance of the work for which this permit is issued. I shall not employ
I certify that in the pem
any person in any manner so as to become subject to tee Worke ' Compensation Laws of car-
All roofs shall be inspected prior to any roofing material being
fernia.
installed. If a roof is installed without first obtaining an
Date �/ / /.� Applipant q
inspection, I agree to remove all new materials for inspection.
NOTICE O AP LICA�NT: If, atter making t a CeR ate ,ptio;Kau should became
A Ilcant understands and will comply with all non point
PP P Y P
subject to the Workers' Compensation provisions of tl a Lab de, you must lorlhwilh comply
with such provisions or this permit shall be tleemetl revok
source regulations.
I certify that I have road this application and state that the above Information is correct. I agree
to comply with all city and county ordinances and state laws relating fobuilding construct ion,end
All roof covenn to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property lot in-
spection purposes.
(We) agree to save, indemnify and keep harmless the City Cupertino against liabilities,
judgments, costs and expenses which may in any way accrue against said City in consequence
SIG T E APPL NT 'DATE
of No granting of this permit.ermit.
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