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OFFICE COPY
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APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
" REROOF PERMIT (406) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
• WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
_
BUILDING ADDRESS / ' f �d h q�—L�D
lD �O
O -3
3 7.5y (S
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
O
YES ❑ If yes — I understand that a Class A
NAME
roof assembly is required.
NO ❑ Initial I.C.B.O. #
EXISTING ROOF COVERING
(�
ADDREss rl
II,_,
NUMBER OF EXISTING COVERINGS F1,1 -/S kfak,
PHONE U
CONTRALTO 'S
yn
TO BE REMOVED_' /'11-'�S TO BE RETAINED
NAME f c5 4 NVQ /` , C) ✓1'l
_q.�L_s;_^�_
.N p i
ADDRESS// ^
TYPE OF ROOF COVERING
CITY B ZIP 'LZ9.l. )_1 LGJ 41/ Ston A1C— CQ SISI
EXISTING
PHONE('642 VVP- OG 977
`
BUILT-UP ROOF ❑ �1a </� �
LICENSE
93
NUMBER 10 Z
ASPHALT SHIN L ❑
LICENSED CONTRACTORS DECLARATION
I hereby of irm that I am licensed under provisions o1 Chapter 0 (commencing with Section
WOOD SHAKE ❑
7000) of Division 3 of the Business and Professions Code, and my license is in full force and
effect. C� 4
License Class I_ Lie Number
WOOD SHI
� ❑
09" TO " C-00 I
OTHER (SPECIFY)/O
Data Common,
OWNER -BUILDER DECLARA IO
^^
PROPOSED ✓
1 hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec. 7031.5, Business and Professions Cade: Any city or county which requires a permit to
construct, alter, improve, demolish, or repair any structure, to its issuance, also requires the
p
�t`'1P
prior
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 0 (commencing with Section 7000) of Division 3 of the
Ct,
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).):
do
WOOD SHAKES ❑
0I, as owner of the property, or my employees with wages as their sole compensation, will
the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Proles
Sion Code: TheContractor's License Law does not apply to an owner of property who builds or
WOOD SHINGLES El
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) ❑
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 Code: The Contractors License Law 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 contractm(s) licensed pursuant to rho Contmclor's License Lew.
PROVIDE III INSTALLATION SPECS.
1 am exempt under Sec. ,B & P. C. for this reason
Owner Data
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of rhe following declaration:
❑ 1 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.
have and will maintain Worker's Compensation Insurance, as required by Section 3700 0l
Seismic
Ih La or Coda, for the performance of the work for which this permit is issued. My Worker's
✓' O
Q�]
9 9/ o
Total
Compensation Insurance carrier tl olic number ere:
03 ZS(
Carrier, 1�p✓{ CtY\— V— Policy No.iBQO01. q�OO
PERMIT A THORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed if the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this permit is issued, I shall not employ
any person in any manner so as to become subject to the W kora' Compensation Laws of Cal I.
All roots shat be inspected prior to any rooting mate lel being
form..
installed. If a roof is installed without first obtaining an
Date -� Applican,
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It, alter making this O rbfic t Exemptio ou should become
subject to the Workers' Compensation provisions of the L or Code, tat forthwith comply
Applicant understands and will Comply With all non point
PP P Y
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.) agree
to comply with all city and county ordinances and state laws relating to building construction, and
All roof coverings to b class "C" or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spectionpurposes.
(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
SIGNAT APPLI 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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