99110181 3 �o
PERMIT
"APPLICATION FOR CITY OF CUPERTINO NUMBS
AMM
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
150 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
34 RESIDENTIAL COMMERCIAL OTHER
O ER'S HAZARDOUS FIRE AREA
YES ❑ If yes—1 understand that a Class A
NAMEroof assembly is required.
q / NO ❑ Inual I.C.B.O.#
ADDRESS (� jo EXISTING ROOF COVERING
PHONE
9 NUMBER OF EXISTING COVERINGS +�
CONTRACT
NAME
TO BE REMOVED_� TO BE RETAINED
@-L L N ��
w ADDRESS /_-�7 ai,5 Rau ��j/� TYPE OF ROOF COVERING
CITV 8 ZIP CUG,\ EXISTING
PHONE�Frl / ,/ ? - BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
]000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect.
/� — �.//� .r/f� 5020 90 WOOD SHINGLES
License Classtc.L(_r_6120 Lic.Number
Datri— I/ 00 Contractor.-J
/ - >� OTHER SPECIFY L7
LU.!(yy s (
OWNER-BUILDER DECL License
PROPOSED
hereby 9llBu that am exempt from the Contractor's License Law for the following reason.
coos.7031.5,Business and Professions it any Any city or county which requires permit to
construct,alter,improve,demto file signed statement
atementhatstructure,prior toils Issuance.to theprvirequires the BUILT-UP ROOF
applicant for such permit to lila a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9(commencing with Section]000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged
ASPHALT SHINGL v `_
exemption.Any violation of Section 7031.5 by any applicant lore permit subjects the applicant to T�
1 1
e civil penalty of not more than five hundred dollars($500).): r�\� �
❑l,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES NOV-241999
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes-
aionSCode:Thal, an who
Licence Law does elf or
hisoapply to an n employers,pho rovide that WOOD SHINGLES NOV 2� 1999
improves thereon,and who tloensuch work himself of Through his own employees,improvement
that
such improvements are not intended or offered for sale. ill however,the building pr or improvement
n rsold build or improve for purpose
sine ownerbuilderwill have the burden of proving that he did OTHER (SPECIFY) y_
----
not 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 Law does not PROVIDE LC.B.O. BRQRT NO_
apply to an owner of property who hands or improves thereon,and who contracts for Such projects
with a con ractor(s)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 Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE_
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, L / Building _
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Seismic
1 have and will maintain Worker's Compensation Insurance,as required by Seclian 3]00 of y�
the Labor Code,for the performance of rho work for which this Permit is issued.My Worker's ^/ a
Compensation Insurance carrier and Policy number are: d_ (�f Ll�''7 Total
Carrierr°P C-e/vr9I Policy NO.WA/99$0Ia329-49/ PERMIT AUTHORIZATION DATE
CERTIFICATE 6F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 _2
(This section need not be completed if the p It Is for one huntlretl ($100)or loss.)
1 certify Ihal In the performance of the war for hion this permit is i Red. shall not employ
any person 1n any manner so as to become ubjeo to the coo era'co ton Laws of Cali. All roofs shall be inspected prior to any roofing material bei6g
journal. q installed. If a roof is installed without first obtaining an
Date)(^Z/— /C1 Applican inspection,i agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter maki his Certificate of Exemption,you should become Applicant understands WIII comply with all non point
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. $ regulatlOnS.
1 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 stale laws relating to buildingconstruction,and ll roof overi St0 C S;&r better.
hereby authorize representatives of this city to enter upon the above-mentioned property for
in-
spection purposes. (%�Jv✓ I l—C�7—
(Wel agree tos save,indemnify and keep harmless the City ai Cupertino against sequins
judgments,costs and expenses which may In any way accrue against said City in consequence 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY