99110179 0013 cQ 31C.- 4f3 -Uu
99/10 7q PERMIT
APPLICATION FOR CITY OF Cu ERTINO NUMB
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 'x/
RESIDENTIAL ' COMMERCIAL OTHER_$_
WNER'S /f q HAZARDOUS FIRE AREA
Je L, ti_Y [�� YES ❑ If yes s I mbly understand Nat. Class A
NAME (/( w�D(/L i,11 roof assembly is required.
/ p / NO ❑ Initial I.C.B.O.u
ADDRESS ! cI ( ,L D D�r /rC.k.O �f- EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS 2
CONTRACTOR'S ` 1 C
TO BE REMOVED - TO BE RETAINED
NAME
ADDRESS �i —�— TYPE OF ROOF COVERING
CITY&ZIPs I�( -7� T llL EXISTING
PHONE 1-177 BUILT-UP ROOF
CENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed 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 full force and
effect.
/� '7/� WOOD SHINGLES
License/Class `� �"Cic.Number ^
Data laZ -2 1-� contractor -t// ii' �S OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED D�
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
construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed 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 SHIN /L-ES Q
' exemption.Anyviolation of Section 7031.5 by any applicant for a permit subjects the applicant to �G/
a civil penalty of not more than five hundred dollars($500).): WOOD SHAK ❑
❑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. N fi
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHIN S O 9 IMLIn
improves thereon,and who does such work himself or through his own employees,provided that ^+19
Such improvements are not intended or offered for sale.IL however,the Wilding or improvement
is sold within one year of completion,theowner-builder will have the burden of proving that he did OTHER(SP FY)__ 1:1not 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 Cade:The Contractor's 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 Law. PROVIDE MFGR. INSTALLATION SPECS.
C]I am exempt under Sec. ,B&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: �--/.-�.�
[:11 have and will maintain a Certificate of Consent to self-insure for Warker'e Compensation, I t 7�—�j >�+ Building
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this 1 Z
permit is issued,
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of qq Seismic
the Labor Cotle,for the pedormance of the work for which this permit is issued.My Worker's O� 7 S Total
Compensaho surance carrier an olryicy�npumbe,are: G
Carrier � � - / Policy No.JW Q 2'01 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O ^�
(This section need not be completed if the permit Is for one hundre do rs($100)or lass.)
ii
certify that In the performance of the war or hlch this permit's Ssue shall not employ
any person in any manner so as to become biec to the wo ars anon Lawe of coli. All roots shall be inspected prior to any roofing material being
forma'.( s installed. If a roof is installed without first obtaining an
Date - ZI) Applican inspection,I agree to re ve I new materials for inspection.
N TICE TO APPLICANT: If,after mak h Certificate of Exemption,you should become A ant understand and will) comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply P Y
with such provisions or this permit shall be deemed revoked. DrC 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 building construction,and Il roof overin St0 CIas Orbe er.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. l I-25-9ti
(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 Inconsequence ATUR F APPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE'COPY