99110127 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMB
INSPECTION DIVISIONFIERMIT EXPIRATION
REROOF PERMIT (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 COMMERCIAL OTHER-
OWNERS
THERO NER'S I� HAZARDOUS FIRE AREA
1. 1�Sf W oob }}t,, YES ❑ If yes s I understandreq that. Class A
NAME Il T (3 , 1" roof assembty is required.
ADDRESS `l Z'D (�e� (l' EXISTING ROOF COVERING
PHONkq 9%6- 67LNUMBER OF EXISTING COVERINGS Z
CONTCTOR'S
NAME TO BE REMOVED TO BE RETAINED
ADDRESS pr. ,,.� C ��r ( (r Z TYPE OF ROOF COVERING
CITY
PHON I T? EXISTING
�! BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
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 lone and
effect.
�' -3�i 417-0 SOZoq D__ WOOD SHINGLES
License
ense Clas Dc.Number -n� �
Dale )7�31��� ContracmrCaLL�1 W5 OTHER(SPECIFY) ❑ O
OWNER-BUILDER DECLARATION 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 ROOF
applicant for such permit to file a Signed statement that he is licensed pursuant to the provisions
of the Contractors License Law(Chapter 9(commencing with Section]000)of Division 3 of the
Business and Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLE
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to Q'
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES �I ❑ D
El I,as owner of the property,or my employees with wages as their sole compensation,will do
the work,and the structure is net 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 SHINGLES Nov ID 9 1999
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
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 V
the project(Sec.7046,Business and Professions Code:The Contractor's License Law does not PROVIDE LC.B.O.R ORT 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 8 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:
[3 �_`�— �O
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, s� 1•�, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
the Labor Code,for the performance of the work for which this permit Is issued.My Worker's C.. V �--7�
Compensation Insurance carrier and licy numbs re: Total �. ' 'k/
Carrier `f 2YY� Policy No.� 01 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEM TION FROM WORKERS'
COMPENSATION INSURANCE N.C❑
(This section need not be completed if t pe i1 is for ono hand d tlo11 s($100)or less.)
certify That in the performance of the w rk lar hich this permit issu shall not employ
any person In any manner so as to become subje to the rkers' nsaron Lawa o coli- All roofs shall be inspected prior to any roofing material being
fertile installed. If a roof is installed without first obtaining an
Date lI_>_ Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,eller makin ertilicate of Exemption,you should became A licant understa s nd will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply p y p
with such provisions or this permit shall be deemed revoked. ur 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 II rO fDDV Ings o class' or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection
We) purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, t
judgments,costs and expenses which may in any way accrue against sale Ciry in consequence SIG ATU OF 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY