00010169 (2) ODD f 1
IK?1A 35 20 -05 Zf PERMIT R_
APPLICATION FOR ' CITY of CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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
RESIDENTIAL n COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
roof assembly
4i YES [J If yes-I understand that a Class A
is required.
NAME
� � NO ❑ Initial I.C.B.O.tt
ADDRESS�..0 / pp EXISTING ROOF COVERING
PHONE L �F7 NUMBER OF EXISTING COVERINGS
CONTRAC 8hl'S '
NAME ,
1'n-�W� TO BE REMOVED C TO BE RETAINED
///��� ,,n �,/
CITVADDRB Z P0_, � .+++%Y 1�O' W 304 TYPE OF ROOF COVERING
EXISTING
PHONE- �' S-O 4/43 - 6,3 2-3 BUILT-UP ROOF ❑
LICENSE [d
NUMBER ZO Z QQ ASPHALTSHINGLES ❑ O
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 Cotle,and my license is in full force and
effect.
C 3 t� 2 DO WOOD SHINGLES
License Class Lid.Number
Date 3OEl
0 O Contractor
OTHER(SPECIFY)
OWNER-BUILDER DECLAR ION PROPOSED
I hereby affirm that I am exempt from the Contractors 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 Law(Chapter 9(commencing with Section 7000)of Division 3 of then a
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES._. CSC-7C-.
S-]
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($500).):
❑1,as ownerof the property,or my employees with wages as their sole compensation,will do WOOD SHAKES
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Obese—
cions Code:The Contractors License Law does not apply gen owner of property who builds or WOOD SHINGLESI
�r D
improves thereon,and who does such work himself orthroughhis own employees,improvement
that lul JAN 2� 2000
such improvements aro not intended the
offered for sale.ff,however,the building or improvement
is within
provyear forpurmpletofstheowner-builderwillhave the burden ofprovingthat hedid OTHER(SPECIFY) El
not builtl or improve far purpose at sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O. LEFORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractor(s)licensed pursuant to the Contractor's License Law.
❑I am exempt under Sec. ,B$P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Building -
permi Is issued. �G/OO
I have end will maintain Worker's Compensation Insurance,as required by Section 3700 of ` G` ��I S'SO S21SmIC
th Le or Code,fourythe performance of the work for which this permit is issuetl.My Worker's
Compensation ins rync¢carri r ennumber are: Total
carrier ��.7+�74•�yl� 7T Policy No.sRS�—�—/��5
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE N.C.]
(This section need not be completed if the permit is for one hundred dollars($100)or less.) �A
I certify that in the performance of the work for which this permit is Issued,I shall not employ L (� 1-
eny person in any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to an roofing material being
fornia. P P Y g
A -
installed. If a roof is installed without first obtaining an
Data 18 00 Applicant inspection,I.agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Cartificat t Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will Comply with all non point
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.)agree
to comply with all city and county ordinances and state laws relating to building Construction,and All roof coverings to be class°�Or 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,
judgments,costs and expenses which may in any way accrue against said City in consequence SIGNATURE OF APPLICANT
of the granting of this permit. ATE
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
OFFICEICOPY