00010059 -H'0001 L00 NUMB R 1
+' APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (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
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ II yes—I understand that a Class A
NAME Itool assembly is required.
/vel1 NO ❑ Iniba I.C.B.O.q ix
ADDRESS ✓ (Q/�� u , \ EXISTING I
NG
PHONE 1� NUMBER OF EXISTIN ERINGS
CONT 'S 1
TO BE REMOVED TO BE RETAINED
NAME Vcuc
ADDRESS TYPE OF ROOF COVERING
CITY 8,ZIP
EXISTING
r
.PHONE BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em 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 lull force and '
effect.
(1 � WOOD SHINGLES ❑
License Cie Lie.Number
' OTHER(SPECIFY) ❑
Oats Contractor
OWNER-BUILDER DECLARATION P P D
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to - F,� JAN
construct,alter,improve,demolish,or repair any structure,prior to eta Issuance,also requires the BUILT-UP ROOF
applicant lar such permit to lila a signed statement that he le licensed pursuant to the provisionsof the Contractor'.Licence Law(Chapter 9(commancing with Section 7000)of Division 3 of the2 2000
Business antl Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLESexemption.Any violation of Section 7031.5 by any applicant far a permit subjects the applicant to
a civil penalty of not more than five hundred dollars f$500).): WOOD SHAKES❑1,as owner of the property,or my employees with wages as their sole compensation,will do the work.antl the structure Is not Intended or offered for sale(Sec.7044,Business antl Profes-
aeons Code:The Contractors License Law does not apply to an owner of property who builds or WOOD SHINGLES Q--•
Improves thereon,and who does such work himself or through his own employees,provided that
such Improvements are not intended or atoned for sale.ll,however,the building or Improvement
Is sold within one year of completion,the owner-builder will have the burden of proving that he ditlOTHER(SPECIFY)
not build or Improve for purpose of sale.).
❑1,as owner of the property,em exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds Or Improve$thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner oats
WORKER'S COMPENSATION DECLARATION 'APPLIIFCA ION DATE VALUATION PERMIT FEE
1 hereby affirm under penalty of perjury e one of the following declaration:
for o I��
eveand will mctnt37a of the
Consent de,for tosell-Insurefor of
'e Compeneall his I 1 Building
as provided for by Section 3700 0l the Labor Code,for the performance of the work far which this
permit Is Issued. Seismic
��l have antl will maintain Worker's Comps setion Insurance,as required by d,My
Worker's of
th or Code,for the performance of the rk for which this permit is Issued,My Workers Total
-Compensa on near c Carrie lid Policy Oar ere: �'rrT�/
Carrier Policy No(� V PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ -••cam
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
I certify that In the performance of the work for which this permit Is Issued,I shall not employ
any parson In any manner so as to become subject to the Workers'Compensallon Laws of Call- All root.^•shall be inspected prior to any rooting material being
torula. installed. If a root is installed without first obtaining an
Dale Applicant inspection,I agree to remove all new materials for inspection.
NISsubject
o t eOWorrkeres'Compense Ion provisionls of theflcate of Labor Code,Exemption,
must forthwith comply
Applicant understands and will comply 'th all non point
with such provisions or this permit shall deemed revoked, source re UQtons.
I certify that I have read this application and stale 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 too ov rings to
class" orb fie
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. f
(We)agree to.ave,Indemnity and keep harmless the City of Cupertino against liabilities, 1
judgments,caste and expenses which may In any way accrue against said City In consequence - URE O AP LICANT 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
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