00020028 (2) (0 2 D�2g
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R—
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 ADDRESS
/0/3 z ,dl ,
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAMEYES ❑ If yes—I understand that a Class A
roof assembly is required.
NO E3Initial I.C.B.O.q
ADDRESS �j �� EXISTING ROOF COVERING
PHONED O �S — NUMBER OF EXISTING COVERINGS I
C O
CONTRA
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP'
(/ EXISTING
PHONE` `T —�l9�7� BUILT-UP ROOF ❑
LICENSE r��+
NUMBER 6k1IASPHALT 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. C 3 4 Q'�� WOOD SHINGLES ❑
license Cla s � Up.Number "'V
Data �� �� Contra
mor OTHER(SPECIFY) E]
OWNER-BUILDER DECy or c N PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason. y
(Sec.uct, It Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve,demolish,sign d statement any
he prior to its issuenco,also requires the BUILT-UP ROOF
applicant far such permit to file a signed statement that he is from pursuant to the provisions
®
of the Contractor's License Law(Chapter 9(commencing with Section 1000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES
exemption. violation Section by any applicant for a permit subjects the applicant to
a civil penaltylty hundred
of not more than five huntlred tlollers($500).):
L]1,as owner of the property,or my employees with wages as their said compensation,will do WOOD SHAKES ❑
the work,and the structure is not intended or offered for sale(Sec,7044,Business and Profes-
sionsCode:The Contractor's License Law d6esnolfj to'8ir ner'of property who lifunds or WOOD SHINGLES
improves thereon,and who does such work Himself or through his own employees,provided that ❑
such improvements are not intended or offer d for sale.If,however,the building or on
is sold within one year of completion,the ow IL)
will have the burden of proving th4I he did OTHER(SPECIFY)
not build or improve for purpose of sale.). L) f1
❑I,as owner of the property,am exclusio ly ntppcc��nt1QQyyuulth pro to t dr.truct
the project(Sec.1044,Business antl Profes Ir
ns C�tlGl1iB Contr6at�c'kAa IFlse�a``�'toes not PROVIDE LC.B.O.REPORT NO.
apply to an owner of property who builtls or i f)loves thereon,an tl wlhra contracts for 1ut11 prolacts
with aconVactmatulicensed
Se pursuance th Contractor's License Law. �J PROVIDE MFGR. INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for thi reason
Owner -- --- —11 APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sellinsure for Worker's Compensation, i Buildin
as provided for by Section 370D of the Labor Code,forthe performance of the work for which this �/ / �. g
permit is issued. OU ��. S d Seismic
have and will maintain Worker's Compensation Insurance,as required i su Beckon Worker's's �n
th Labor Code,for the performance of the work for which this permit is issued.My Workers O
Cam ensatlon nsu carrier antl Poli number are: Total
P /�/y 1 G
Carrier � 12kllp - /n-^ Policy No 11) 2'70 •5 Z1 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NOQ r
(This section need not be completed if the permit is for one hundred dollars($1 OD)or less.) ^1 'Z— _ Z OOH
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 became subject to the Workers'Compensation Laws of Call- All roofs shall be inspected priorto any roofing material being
forma. installed. If a roof is installed without first obtaining an
Data I/_/7 00 Applicant Ae•�✓�= inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate 61 Exemption,you should become Applicant understands and will
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP comply P y with all non point
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that 1 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 bulleing construction,and All roof coverings to be class 6r 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, Z 6b
judgments,costs and expenses which may in any way accrue against said City in consequence DATE
oIthegrantingofthispermlt. SIGNATUR FAPPLICANT
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