00010078 (2) � — o 00 -7"Y"'
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R-
,/'• � INSPECTION DIVISION - PERMIT EXPIRATION -
RER00 F PERMIT 408 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
( )
- - WITHIN 180 DAYS OF PERMIT ISSUANCE OR
I ` • _ 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL— COMMERCIAL OTHER '
DWNERL's�G ^/ HAZARDOUS FIRE AREA
/ L / N)�K/YWl'w VES ❑ II yes s I understand that.'Class A,
NAME / root assembly is required:'
' NO ❑ - - Initial LC.B.O.#
ADDRESS • ''I / / - EXISTING ROOF COVERING -
PHONE _ / �(f O (p - NUMBER OF EXISTING COVERINGS. L '
CONTRAC R /
TO BE REMOVED Z -TO BE RETAINED ( .
NAME
TYPE OF ROOF COVERING
�.�
CITY&
AbD6ESP�s� fN/N.nYIA:� ALII' �� /a-Ge GLGL� '�•� - - •
EXISTING
PHONE �J� �—�o J� 73 • BUILT-UP ROOF ".❑.�1 / +
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION : Q
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. - Q O - WOOD SHINGLES
_ ,License Class Lic.Number '
t pp
Contracidr OTHER(SPECIFY) ❑ '
Data -
OWNER-BUILDER DECLARATI 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 +OOF
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions - 77
of the Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the II I
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged .ASPHALT SHINGLES �2
exemption.Any violation of Section 7031.5 by any applicant for a Permit subjects the applicant to y1( .
a civil penalty of not more than five hundred tlollars($500).): WOOD$t;l
EAN �-�oo
❑I,as owner of the property,crony 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 LES
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 l,
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER($PECIF`V)
' 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 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 contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.-
❑I'am exempt under Sec. ,B&P.C.for this reason
OwnerDole
WORKER'S COMPENSATION DECLARAATIONTION APPLICATION DATE VALUATION -•PERMIT FEE
-
I hereby affirm under penalty of perjury one of the following declaration:
I]I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, 00
,
as provided for by Section 3700 ofthe Labor Code,for the performance of the work forwhich this Building
/ �y/av J ��d
p r is Issued. J Seismic
ve and will maintain Workers Compensation Insurance,as required by Section 3700 of //'� / a
th Labor Code,for the performance of the work for which this permit is issued.My Worker's TOIa/
Compensation Incce ur rrier and Policy number are:
Carrier ^�'�/---�� Policy Noes 7/-x/9//L.� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NA.[]
(This section need not be completed it the permit is for one hundred dollars($100)or less.) 77 T
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 Wo o cempensati Laws of Cali. All roofs shall be inspected prior to any roofing material being
feria. installed-' If 'a roof is installed without first obtaining'an
Dare / 0 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making ihi3Certificate Exemption,you should become Applicant understands and will
subject to the Workers'Compensation provisions of the Lab r Code,you must forthwith comply pp comply p y with all non point
with such provisions or this permit shall be doomed 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 CoWrmi be cls s &r better. -
hereby authorize representatives of this city to enter upon the above-mentioned property for ion.,spection - • //�/6O
(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 SIGNATURE APPLICANT DATE
a 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 FORANSPECTION
OFFICE COPY - '