00030211 (2) - PERNu
APPLICATION FOR ' CITY OF CUPERTINO NUMB��
' Cp INSPECTION'DIVISION- PERMIT Ex IR ION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
k� 180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS' /g/ A/ � _ [,tom/
V(�j`, - RESIDENTIAL COMMERCIAL OTHER
owNER's HAZARDOUS FIRE AREA
VES ❑ If yes—I understand that a Class A
NAMEroof assembly is required.
A NO ❑, Initial I.C.B.O.9
ADORES LIZ�Tj Z EXISTING ROOF COVERING
PHONES O J S ��O..J �. �/ NUMBER OF EXISTING COVERINGS
CONTRACT 'S
NAME TO BE REMOVED �j/�l-� TO BE RETAINED Ti L e
'
ADDRESS —^7 7]�{j /� /�"j/ TYP OF RO F 9 OVERT G
CITY,&ZIP�� I ` kr "
f} EXISTING
PHONE(5i110 BUILT-UP ROOF -
LICENSE / `1 O`7
NUMBER /O� C� - .'ASPHALT SHINGLES _ co,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
effect. � 39 "7. /S WOOD SHINGLES ❑
0 2 '
License Class Lia Number '
Date -BUIL t OTHER(SPECIFY)
OWNER-BNLDEfl DECLARATION _ '
I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason. PROPOSED.
(Sec.7031.5,Business and Professions Code; Any city or county which requires a permit to -
con struct,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 Law(Chapter 9.(commancing with Section 7000)of Division 3 of the -
Business and Professions Code)or that he is exempt therefrom andthe basis for the allegetl ASPHALT SHINGLES '❑ -
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the apirl[cant to
a civil penalty of not more than five hundred dollars($500).):-
❑1,as owner of the property,'or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profen. - -
sides Code:The Contractor's License Law does not apply to an owner of property who builds of WOOD SHINGLES
improves thereon,and who does such work himself or through his own employees,provided that ❑ DD�
such improvements are not intended or offered for sale.If,however,the en of pr or improvement Z�yO
is sold within one year of completion,the owner-builder will have the burden of proving that he die
'OTHER(SPECIFY)
not build or improve for purpose of sale.).
E]1,as owner of the property,am exclusively contracting with licensed cnlrociors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE LC.B.O. REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law.
❑I am exempt under Sea- ,B e,P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
Owner - Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
hereby affirm under penalty of perjury one of the fallowing declaration: O
I]
I have and will maintain a Certificate of Consent to self-insure for Worker's'Compensation, 3/✓v Q 4 Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /OO / • ��
permit is' Seismic
ave and will maintain Worker's Compensation Insurance,as required by Section 3700 of -
t ebor Code,forthe pertormance of the work for which this permit is issued.My Workers' - '
ompens ion lnsuranc carrier end Policy numberare: r ' 2 6:, Total
carriar� Policy No.�� /✓ bPERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' _
COMPENSATION INSURANCE N.C.I]
(This section neetl not be tour a if the perm one huntlre o)or Isms) y3�p26
` certify that in the partormance t the work for which this tit is etl, shall n mploy, - V
any person in any man r so as to b 1e subject to the Worker ompen ion L., o r. - All roofs shall be inspected prior to any roofing material being
torero. �Q installed. If a roof is installed without first obtainingan
Date Applicant inspection,I agree to remove all new materials for inspetion.
NOTICE TO APPLICANT: If,after making thisarrfidate of Exemption,you ehomd'be e Applicant understands and will,comply with all non Dint .
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pp p y p
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that l have read this application and state that the above information is correct l agree
to comply with all city and county ordinances and state laws relating to building construction,and II r0 err gs to s"C"or better. -
hereby authorize representatives of this city to enter upon the above-mentioned property for in- /�O x.��-
spectido purposes.
(W /
e)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, -
judgments,costs antl expenses which may In any,way accrue against said City in consequence - DATE
d/ he granting of this permit: - SIG OF AP -
41 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 ,
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OFFICE COPY