00040031 goo 4 603
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R-
INSPECTION DIVISIONPERMIT 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.
BUILDIWi ADDRESS
/O �j/�(ol Scents .�r
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
�, /' YES ❑ If yes—I understand that a Class A
NAME ZV a )V Snns roof assembly is required.
NO ❑ Initial I.C.B.O.If
ADDRESS /10 Xa / Cool t,Z— I Y EXISTING ROOF COVERING
PHON O ^Z NUMBER OF EXISTING COVERINGS fill
CONTRACTOR'S /y��
rkY1 G2 ICQn F I..o TO BE REMOVED_ e TO BE RETAINED
NAME �6C-��1 + .
ADDRESS t TYPE OF ROOF COVERING
CITYaziPza-�12 �.n..�/u /,1.� Sun Icse C� 45)2l EXISTING
PHONE -06Y,7 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
7000)of Division 3 of the Business and Professions Code,and my license is in full force and V\
effect.
WOOD SHINGLES
License Class ��9 Lic.Num or
Data 09 71 /o OTHER(SPECIFY) ❑
;�X Contractor O
OWNER-BUILDER DE A PROPOSED
I hereby affirm that I am exempt from the Contractor's LI iu w for the lollowing 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 Elapplicant 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 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 five hundred dollars($500).): WOOD SHAKES
[3I,as owner of the property,or my employees with wages as their sots compensation,will do
the work,and the structure is not intended or offered lot sale(Sec.7044,Business and Proles-
sionsCode:The Contractor's License Law does notapply to on 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) ❑ 7�0.V i�
not build or improve for purpose of sale.). a
❑I,as owner of the property,em exclusively contracting with licensed contractors to construct r'
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. �5
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(a)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.lot this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
FT I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. _ $QISRIIC
Q�have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Q
the Labor Code,for the performance of the work for which this permit is issued.My Workers /3 / �� Total
Compensation Insurance earn and Poli number ere:
1
carrier AyY N &jx �j'� 1 0y" Policy No. SID9002.3 K" 00 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ �j 7
(This section need not be completed if the permit is for one hundred dollars($100)or less.) 5/ - D /'J
—003 O OS OD
certify that in the performance of the work for which this p rmit Is Issued, shell not employ
any person in any manner so as to become subject to the We,are Compensation Laws of Cali- All roofs shall be inspected prior to any roofing triaterial being
fornia. installed. If a roof is installed without first obtaining an
Date 0 00 Applicant inspection,I agree to remove all new materials for inspection.
NOTIc TO APPLICANT: If,after making this ce diva of Exem ' you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the or Cotle,you must forthwith comply pP P Y P
with such provisions or this permit shall be deemed revoked. source 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 All roof coverin s be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, d
judgments,costs and expenses which may in any way accrue against said Clry in consequence SIGNAT R AP CANT AT
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN ROGRESS:
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
OFFICEICOPY