99120104 (2) 3S17 - loci-:2.$
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER _
R
INSPECTION DIVISION PERMIT EXPIRATION
RER OF ERMIT ` (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
- l
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
WI18D DAYS FROM LAST GERMED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL— OTHER
OWNER'S HAZARDOUS FIRE AREA
yn'I YES ❑ II yes—I understand that a Class A
NAME '41C ,—/nom root assembly is required.
NO Irahel I.C.B.O.F
ADDRESS J EXISTING ROOF COVERING
PHONE v
7aP i /I Z 3 NUMBER OF EXISTING COVERINGS Z_
CONTRACTORS
D/J 70 BE REMOVED Z� TO BE RETAINED L
NAME • 1s C,
ADDRESS t / — ' TYPE OF ROOF COVERING
CITY&ZIP �(�, .3'1'
EXISTING
PHONI 861-7GQ9 BUILT-UP ROOF
LICENSE
NUMBER Z�lOY ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES [�
]000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect.
o WOOD SHINGLES
�leanse,C�las�s� ��� Mic.Number ^"' 0 V A
Date�1lo/ Contractor OTHER(SPECIFY) ❑ V
OWNER-BUILDER DECLARATI PROPOSED
1 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 e permit to n^
construct,alter,improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROO9
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 I/
)
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SH�jr[_B , D
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to Uu�t 'r
a civil penalty of not more than five hundred dollars($500).): WOOD SHA S 1 /b
• 1�01,as owner of the property,or my 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:Tho Contractor's License Law does not apply to an owner of property who builds or WOOD SHI Gh
improves thereon,and who tloes such work himself or through his awn employees,provided that ❑
such improvements are not intended or offered for sato.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,em 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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
01 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, O� Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
per is sued. 711 Seismic
have antl will maintain Worker's Compensation Insurance,as required by Section 3]00 of Illiii
th Labor Code,for the performance of the work for which this permit is issued.My Worker's
Compensation Baron cg tier Policy n ,oar are: /.D1.� f Total
Carrier Policy,4±_) O[SZ�65 PERMIT AUT OR ZATION DATE
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ �^
(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 Laws of Can- All roofs shall be inspected prior to any roofing material bein
fornia. installed. If a roof is installed without first obtaining an
Date t17 Applicant - inspection,I agree to remove all new materials for inspection.
NOTICE T6 APPLICANT: If,after making this Certif'ate of Exemption,you should became Applicant understands and will I with all non point
subject to the Workers'Compensation provisions of th Labor Code,you must forthwith comply PP comply Y P
with such provisions or this permit shall be deemed 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 slate laws relating Io building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spe) purposes.
(W . /
(we)agree to save,indemnity and keep harmless the City ai Cupertino y in againstliabilities, (/
ofthe gran costs and expenses wM1lch may in any way accrue against said City in consequence SIGNATUR F APPLICANT 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
OFFICEICOPY