99110170 i l0Ll 3 005
" 1�7-q9j/D/70 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION -
K EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
1e0 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
i YES ❑ It yes-I Understand that a Class A
NAME �e S-F-UJOB[� • root assembly is required.
GG��n C'1 NO E] Initial I.C.B.O.N
ADDRESS I9 l �-� yye- � J/ EXISTING ROOF COVERING
PHONE Q 7 NUMBER OF EXISTING COVERINGS 2
CONTRACTOR'S C1�
TO BE REMOVED X TO BE RETAINED
NAME
ADDRESS77 L� � TYPE OF ROOF COVERING
CITY&ZIP S l�lp ICS J ! EXISTING
PHONE 7�� / 7 /7 ? BUILT-UP ROOF
LICENSE E]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
affect.
/� JJ� � � u WOOD SHINGLES ❑
License C^Ias3`- t C' 4!�qIc.Number
Dat /2� J/-O-c> ContmctorSec44r/14 2088-, OTHER(SPECIFY)
OWNER BUILDER DECLARATION PROPOSED
1 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 LLL��mrr
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 �j�
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHING S / z_-1\
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).): WOOD SHAKES D
C]I,as owner of the property,or my employees with wages is their sole compensation,will do NOV ❑
the work,and the structure is flat intended or offered for sale Sec.7044,Business and Profes. /},1Q(](�
sides Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGL LJ•vJJ
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-buildor will have the burden of proving that he did OTHER(SPECI ! ❑
not build or improve for purpose of sale.). ��-
1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT N
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a eontractons)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: ///y�� ^�
❑1 have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, I (� 07 N ` S-DO Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this 1 / !
permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of .7,5 �S Seismic
the Labor Code,for the performance of the work for which this permit is issued.My Worker's NJ� /
Compansmio sumnca carrier and Policy number are: Total
carrier Policy NAW ft Y03a7-L PERMIT AUTHORIZATION DATE
CERTIFICATE OF EX MPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 / Q
(This section need not be completed if the pe 't is for one bond, d do are($100)or less.)
I certify that In the performance of the war or w ich tnis p rmit is a4 shell not employ
any person in any manner so as to become bid t the Wo rs pensation Laws of Call- All roofs Shall b inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date 1_1—J�— APPlican inspection,I agree to em a all new materials for inspection.
NOTICE TO APPLICANT: IL after maker is Certificate of Exemption,you should become Applicant understa ds an 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 shall be deemed revoked, s r 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 build ng construction,and 11 to f COVef gst ass Or flet.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. 11i Zy-
(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 in consequence A LJ E OF 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