99110131 � ll0 01
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUM
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS — /�
6 {W�C�i W{�C�� 2� RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
n _ YES ❑ It yes—I understand that a Class A
NAME
WC 7 WQf'7 roof assembly is required.
l o NO ❑ Initial I.C.B.O.#
ADDRES�Sr10t�2G6R o�� ctilJ olod S i EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S �
(a,(,\�f •�'��( y57�-x-�S TO BE REMOVED TO BE RETAINED
NAME
ADDRESS � TYPE OF ROOF COVERING
CITY B ZIP6-7?`_ S �ow ST J � J Ir7
EXISTING
PHONLc"� O�jJ )�] BUILT-UP ROOF
CENSE
NUMBER ASPHALT SHINGLES (❑
LICENSED CONTRACTORS DECLARATION
I hereby a#iran that 1 am licensod under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is in lull force and
effect.
35 +l `0 -0 5 WOOD SHINGLES El
License Clas Lic.Number
Data 9-at-®O comracmr t OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
con struct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a all statement that he is licensed 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 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
a civil penalty of not more than live hundred dollars($500).):
]I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES M�1g1 91999
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes- LJ
sions Code:The Contractor's License Law 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.It,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.). Y
I,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 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 contractogs)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 Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
01 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, V
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this �t SO Building
permit is issued. `
❑I have and will maintain Workers Compensation Insurance,as required by Section 3700 of S Seis mlc
the Labor Code,for the performance of the work for which this permit is issued.My Worker's
Compensation Insura�nce1carrriier an Po/ly/y number aro: Tota O�
Carrier FC—C OYV '.f-t lrhY Policy No 2?-& PERMIT AUTHORIZATION DATE
CERTIFICATE 9F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 100)o /�
(This section need not be completed if the a it is for ane huntlred tl Mars 100)or less.) (/
1 certify that in the performance of thew k for ich this permit a is ed, hell not employ
any person in any manner so es to bosom ubject o the orkers'cam
on to Laws of call- All roofs shall be inspected prior to any roofing material be61g
feria, installed. If a roof is installed without first obtaining an
Date a_gs Anciff n inspection,I agree to remove ail new materials for inspection.
N ICE TO APPLICANT: II,after making th Certificate of Exemption,you should become Applicant understands an will comply with all non ort
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit shall be deemed revoked. T e regulations.
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 Wilding construction,and o fCOV ingstobeC SS O better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spectionpurposes. 1� IQI—
(Wo)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, l I
judgments,costs and expenses which may In any way accrue against said City in consequence SI T R OF APPLI ANT 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
OFFICECOPY