00010003 (2) 3 4 2.,5`- v v 00 000JIr
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMB
INSPECTION DIVISION PERMIT EXPI ATION
REROOF PERMIT (408) B PERMIT EXPIRES IF WORK ISNOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
-3�ING ADDRESS
06 0 6/ ec'Iu"ecki 14Ve,, 1 0 MMERCIAL OTHER
OWNER'S U HA7AGlIl FIRE AREA
NAME E s st d t a Class A
O _ filial I.C.B.O.N
ADDRESS EXISTING ROOF COVERING
m
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACT
@/'(�B /p TO BE REMOVED TO BE RETAINED
NAME �I CH �. f/' �✓L
ADORES s TYPE OF ROOF COVERING
CITY&zIP�LL 2,
C 4 9 3 f 4 EXISTING
PHONE p ��' �� 9• 26l BUILT-UP ROOF ❑
LICENSE
NUMBER ���� - ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby affirm that am si licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
]000)of by affirm
3 of the Business and Professions code,and r 9 license is In lull force end
effect WOOD SHINGLES A,�) F�License Class 00contmcmr OTHER(SPECIFY)tic.NumberDate / n' 0
OWNER-BUILDER DECLARATION PROPOSED "-
I hereby affirm that I am exempt from the Contractor's License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to lI 1\
construct,after,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF `� ❑OJ�
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions I_ p D
of the Contractor's License Law(Chapter 9(commencing with Section]000)of Division 3 of the A
.` Business and Professions Cade)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES �2Af1D
exemption.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($501:
01,as owner of the property,or my employees with wages as their sole compensation,will do WOODSHAKESi �J ❑
the work,and the structure is not Intended or offered for sale(Sec.7044,Business and Proles. I y
stons Code:The Contractor's License Lew does not apply to an owner of property who builds or
improves thereon,and who does such work himself or through his own employees,provided that WOOD SHINGLES ' ❑-"�-
such improvements are not intended or offered for sale.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 CDde:The Contractor's License Lew 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 contractor(s)licensed pursuant to the Contractors License Law. PROVIDE Ml INSTALLATION SPECS.
L1 am exempt under Sec. ,B 9 P.C.for this reason
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, Building
permit is I. for by Section 3700 of the Labor Code,for the performance of the work for which this �,.xp g
permit li ed for
. < l%/�
❑I have and will maintain Worker's Compensaima Insurance,as required by Section 3]00 of rJ Seismic
the Labor Code,for the performance of the work for which this permit is issued.My Worker's
Compensation Insurance ander and Policy number are: /') Tota
Carrier. / / �� r yL Policy No._Lc PERMIT AUTHORIZATION
CERTIFICATE OF EXEMPTION FROM WORKERS'/6 rrL
COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred dollars($100)or less.).
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 Workers'Compensation Lews of Cell- All roofs shall be Inspected prior to any roofing material being
fornix. installed. If a roof is installed withoutfirstobtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate at Exemption,you should become Applicant understands and will comply subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP ply with all non point
with such provisions or this permit shall be deemed revoked. source ulations-
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, ad Allr fD0 erings to class 'or better.
hereby authorize representatives of this city to enter upon the above mentioned property for In-
spectlon purposes.
(We)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
of the
greening of this permit. SIG AT E OFA T D E
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP.-DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE It DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY