99110031 0-3 s'
PERMIT'
APPLICATION FOR CITY OF CUPERTINO NUMBER R" '
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST.CALLED INSPECTION.
BUILDING ADDRESS
f3
AA qT e
� �., `
t �'P�5 I RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME� S O O roof assembly is required.
NO ❑ Initial I.C.B.O.It
ADDRESS S Q - Vin PZ EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACT 1 (�
�C ? TO BE REMOVED TO BE RETAINED
NAME r�� K.A{.8J-si-
ADDRESS rl J® f� Y ��A TYPE OF ROOF COVERING
CITU&ZIPQT�J IV�J/�_2 �(Ll p� �7�c.Kur1. EXISTING ,
PHONE� ( A 3 J BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES 11
LI ENSED CONTRACTORS DECLARATION
I hereby affirm that I am 1lcansed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is in full force and
offset. �_ WOOD SHINGLES
License Class S�rLic.Number ❑
OTHER(SPECIFY)
Date Contractor
OWNER BUILDER DECLARATION PROPOSED 3
1 hereby affirm that I am exempt from the Contractor's License Law for the requires
a reason.
(Sec.construct,
It Business improve and Professions Cotle: Any city or county which re,also a permit to �0
conlucant.elter,Improve,demoto file signedrepair statement that
prior toIts Issuance,to
the BUILT-UP ROOF
of the o for such permit to flaw a signed statement that g IslicensedSectio pursuantnfto the provisionsofthe
of the Contractor's license Law(Chapter 8(commencing with Section 7000)of for the 3 0l the
Business and violation of Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any violationof Section hundred
byany applicant for apermit subjects the applicant to
a dull penalty of not more than five hundred yeesm(h wag): WOOD SHAKES ❑
❑I,as owner of the property,or to ded or oes with wages as their Bole compensation,will s.
the work,and he structure Is not Intended ores not for sale(Sec.7044,Business end Profen
cions Code:The Contractor's License Lew does not apply to an owner of property who betide or WOOD SHINGLES ❑
Improves thereon,and who does such workhimselffor far through his own employees,Improvement provided that f
such Improvements are not Intended or offered for edea.If,however,the building f pr o i Improvement
is notsold bull or
provyear purposetof sae.ownerbuilderwill have the burtlen of proving that he did OTHER(SPECIFY) 7�
not build or Improve for purpose al sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVID t:C:B:07RE\RF
apply to an owner of property who builds or Improves thereon,and who contracts for such projects n G
with a contractor(s)licensed pursuant to the Contractor's License Law. PF Jul IOVID .INSGRTALLA 1•N Si f= S.
❑1 am exempt under Sec. ,B 3 P.C.for this reason
11
Owner Date APPLICATION VAL A PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to sell insure for Worker's Compensation, ulldl ng
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
By—
permit Is Issued. By_ eismlc
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
-the Labor Code,for the performance of the work for which this permit I$Issued.My Worker's O /L�yL Total
Compen ton Insu�nca carrier Po11�fcy��nu�mb/a,r�e�re: / Q� T`^�
Carrie �Z �'fL'1 !riPolicyN 4 -� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.E] ' yA Q
(This section need not be completed If the permit is for one hundred dollars($100)or lees.) "I /
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 I we of Cell- All roofs Shall be Insp cted prior to any roofing material being
fornie. 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 A locant 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
with such provisions or this permit shalf;be deemed revoked. Source regulations.
I certify that I have read this application and state that the above Information Is correct.)agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coy9rrrlTmm���s to be class S. r better.
hereby authorize representatives of this city to enter upon the ebovemantlonetl property for In. /
speedo)purposes.
judgments,agree s save,Indemnexpenses
and keep harmless the Cary of Cupertino y Inagainstcon Ilebllitles,ence _ !7
of the gran costa and expenses which may In any way accrue against sale City In consequence SI TUBE OF APPLICANT DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: I FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY