R 6856I0
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OFFICE'COPY
PERMIT6856
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APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT 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.
BUILDING ADDRESSI-
��
a W V \ �. F�'TT,JrJ
RESIDENTIAL ' COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ❑ It yes- I understand that a Class A
NAME V^y
roof assembly is required.
NO Initial I.C.B.O. N
nn q -e
`I �
t EXISTING ROOF COVERING
ADDRESS I 5;2'9 t -=c `L)
PHONE
NUMBER OF EXISTING COVERINGS I
_�
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME I Vied Lo Y- L2 NJ' -r
ADDRESSI I - &t=TYPE
OF ROOF COVERING
CITY 8 ZIP Sd �
EXISTING
_
9 D , — � )C �
PHONE
BUILT-UP ROOF ❑
LICENSE
NSZ �' G�
44
ASPHALT SHINGLES ❑
WOOD SHAKES J]000)
421
LICENSED CONTRACTORS DECLARATION
I hereby that em licensed antler provisions of Chapter 9 (commencing with Section
of Division 3 of the Business entl Professions Cotle, anti my license is in lull torte and
inion
effect.
3
WOOD SHINGLES ❑
License Class Lic. Number
7AO
OTHER (SPECIFY) ❑
,.to Commcmr
OWNER -BUILDER DECLARATION -OI' �
PROPOSED
I 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
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 Lew (Chapter 9 (commencing with Section ]000) of Division 3 of the
Business entl Professions Code) or that he is exempt therefrom and the basis for the alleged
p�
ASPHALT SHINGLES "'L v,/—
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars ($50011:
WOOD SHAKES ❑
Q I, as owner of the property, or my employees with wages as their sole compensation, will do
the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Profes-
sions Code : The Contractor's License Law does not apply to an owner of property who builds or
WOOD SHINGLES ❑
Improves thereon, and who tloes such work himself or through his own employees, provided that
such improvements are not intended or offered for Salo. 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 Contractor's License Low does not
i
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 contraclods) licensed pursuant to the Contractor's License Lew.
PROVIDE MFGR. INSTALLATION SPECS.
C]I am exempt under Sec. ,B & P. C. for this reason ._
_ _ -
-
Owner Datej
APPLICATION DATE
f1 VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
i!
I hereby affirm under penalty of perjury one of the following declaration: (f
have and will maintain a Certificate of Consent to self -insure for Worker's Comp'""'.1oJ
APR 7 2000
I
Building
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. I
Seismic
❑ I have and will maintain Worker's Compensation Insurance, as required by Section 3]000I
the Labor Code, for the performance of the work for which this permit Is Issued. My Worker]
�� / zz
Compensation Insurance carrier and Policy number are: By
� __
Total
Carrier I/ r i 1 y%i Nu V A Policy No. WC- 3 �O 7` I
PERMIT-AUTHO
N
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCO
(This section need not be completed if the permit is for one hundred dollars ($100) or less.)
I cattily that in the performance of the work for which this permit is issued, I s ploy
any person in any manner so as to become subject to ' Comps ae ...of aIf.
All roofs shall be inspected prior to any roofing material being
fornia.
installed. If a roof is installed without first obtaining an
Date? U U Ano / �—
sp�eR-ragree to remove all new materials for inspection.
NOTICE AP LICANT: If, after making thi ertificate of Exemption, you should become
Applicant understands and will comply with all non point
PP P Y P
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
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 coverings to be class "C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
specllon purposes.
(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 consequenceSI
ATURE 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