00040137 (2) 7S-- 9/- o Z) ,5_ n001110 13
PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBER R-
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (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 /
e RESIDENTIAL ✓ COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
►1 YES ❑ If yes—I understand that a Class A
Pan ave -e.v I V1 roof assembly is required.
NO ❑ Initial I.C.B.O.N
ADDRESS ( �h44eVnl 1 (-U Dl_1(-h K%n EXISTING ROOF COVERING
PHONE — NUMBER OF EXISTING COVERINGS 1
CONTRACTOR'S � -
NAME�n5� hl �) nA TO BE REMOVED /�eS TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP ;Lb?+Z 5F?Yy)G n&,1 &edwoc:,J C 11• t{"H0PEXISTING
PHONE U00 91091-COISI BUILT-UP ROOF A
LICENSE
NUMBER 90 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
hereby egirm 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 J66
effect. �� ��p WOOD SHINGLES
License Class C, Lic.Number 8A {U O®
Data - /11 l06 Contractor RPor�-Y7nS/.k) �ZOOfi/g OTHER(SPECIFY) ❑
OWNER-BUILDERDECLA ATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Cotle: Any city or county which requires a permit to cX
construct,alter,improve,demolish,or repair any structure.prior to its Issuance,also requires the BUILT-UP ROOF qal
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 the
Business and Professions Coda)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑
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($500).): WOOD SHAKES El
I,as owner of the property,or my employees with wages as their sole ccml,ensation,will do
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Protest.
Siena COda:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the building or improvement
is sold within one year of completion,the ownerbullder will have the burden of proving that he dict OTHER(SPECIFY) ❑
not build or improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contusions)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
[:]I am exempt under Sec. ,B&P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
p 1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building
provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. �� I I—QO IU r G Seismic
1 have and will maintain Worker's Compensation Insurance,as required by Section 3700's { _
to L bar Code,for the performance of the work for which this permit is issued.My Worker's a'"'j J. 19
' Compensation Insurance carrier and Policy number are: Total
Carrier LfTo 1 -LYL$t1toIlCP Policy No. wG2(1l0-Ii�O"le+ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[ ^O-P
(This section need not be completed if the permit is lot 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 Laws of Cell- All roofs Shall be Inspected prior to any roofing material being
fernia. installed. If a roof is installed without first obtaining an
Det. 1 'I I—UG Applicant s inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this CeAificate of Exemption,you should baso Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith com PP P Y
with such provisions or this permit shall be deemed revoked. Source regulations.
I certify that I have react 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 coverings to be class-At better.
hereby authorize representatives of this city to enter upon the abova-mentioned property for in.
spection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expanses which may In any way accrue against said City...consequence SI GNATD ANT DATE
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 FOR INSPECTION
OFFICE'COPY