R 5848 PERMIT R_ 5849
APPLICATION FOR CITY OF CUPERTwo NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(406)777-.3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
2'2vE1'2-> \\� ESIDENTIAL COMMERCIAL OTHER
OWNERS _ HAZARDOUS FIRE AREA
NAME r r IN �S YES I roof assembly underssirequirednd that CI
/ I NO ❑ Inilia I.C.B.O.#
ADDRESS / !/C- 'e lit M� —� eh- EXISTING
PHONE �/ 1 �7 NUMBER OF EXISTING COVERINGS
CONTRACTO '
NAME 4i s r -I 1 f W�/�J TO BE REMOVED TO BE RETAINED
ADDRESS ► J �� / TYPE OF ROOF COVERING
V I h
clrvaZIP
y//' / yt NIEXISTING
PHONE—__ ! `�� 1 (®'� `' v ` ✓/
BUILT-UP ROOF ❑Jam,
CENSE
NUMBER ASPHALT SHINGLES ❑uc' //J
LICENS CONTRACTORS DECLARATION J
hereby iaffirmlio that I am usilicensed under emulsions of Chapter B(commencing In with Sectionand WOOD SHAKES
7000)of Division 3 of the Buslneee entl Professions Cotle,entl my Ilonee Is In full tome and
effect.
License Cle Lic.Number WOOD SHINGLES
Date Contractor Pei., li 71 OTHER(SPECIFY)19 JV ❑
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 Professions Code: Any city or county which requires a permit to
coplicaninstruc6orsuimprove,demoto file asignedpalrenentrthate,priortoIssuance,alsorequlree the BUILT-UP ROOF ❑
applicant kr such permit to file sh,or re statement that he Is licensed to Intl pursuant the quire provisions
• of the Contractols License Law(Chapter a(commencing with Section 7000)of Division 3 of the qF
Business and Professions Code)or that he 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
e civil penalty of not more than live hundred dollars($500).):
01,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 Proles.
slons Code:The Contractor's License Low does not apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,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 Bale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractuls License Lew 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 Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B a P.C.for this reason
Owner Data A C T ON DATE VALUATION PERMIT F
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑t have and will maintain s Certificate of Consent to self-Ii ie for Workers Compensation, Q ,av Buildin
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this p(�� 6� J /`�
permit Is Issued. IR l6 O QW'D / / ` seismic❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 W
the Labor Cotle,for the performance of the work for which this permit Is Issued.MyWorkelj( f: `Urtkr Total
Compensation Insurance carrier and Policy number are:
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.00
(This section need not be completed-if the permit one hundred dollars($100)or less.)
I certify that In the performance of the work for hlch 1 permit
la issued hall not employ
any person in manner o as to become eubje t t orker ompe Lawe or call. All roofs shall be inspected prior to any ro fin mat riot g
fornia. installed. If a roof is installed without first obtainingan
are 7� �" Applicant inspection,I agree to remove all new materials for inspection.
ecome
subject l0 theNOT CE f0Workers'Compenlsatliorn provisionls ofethefiLaborr Code,you must fothwlltio tlhbcomply Applicant understands and will comply with all non point
with such provisions or this permit shall be doomed revoked. SOU rCe re ulations.
I certify that l have read this application and state that the above Information is correct.I agree
to comply with all city and county ordinances and slate laws relating to building construction.and All roWREF
obs ss' atter.
hereby authorize representatives of this city to enter upon the above-mentioned property for In. 1
spection purposes. s
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
• of the grantingofthis permit es which they In any way accrue against said Clry In conaequance 31 NPLIf4v IDATE
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