00020040 (2) 3fl nS' ods- o�oz�� o
PERMIT R_ 7600
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
WI180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS I
LRESIDENTIAL —L/— COMMERCIAL OTHER
OWNER'S '/ HAZARDOUS FIRE AREA
NAME _ 1_iU ' v t ��L//"lY S14�A
YES
royal assembly required,radand that e ClassA
I O / NO ❑ Initial I.C.B.O.N
ADDRESS 10 3 :3 s O r) � r� h � U Z EXISTING ROOF COVERING
PHONE r
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ^ /
NAME
�� yLG i, TO BE REMOVED TO BE RETAINED O
ADDRESS ( d I TYPE OF ROOF GVERING
CITY&ZIP "'LIQ 'd' I� ✓' J C
/r _ 4 �7 EXISTING
PHONE '( � S U��7 f�E` 7 BUILT-UP ROOFLICENSE
��
NUMBER v J / 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 lull force and
effect.
C _ -v'? WOOD SHINGLES ❑
License Cla.`` Lie.Number ,
Data 2f J Contra J"""-IS�� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from to Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit Io
construct,alter,improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to life 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 0l the
Business and Professions Sea)or that a is exempt therefrom and the basis forhe the applicant
to ASPHALT SHINGLES
exemption.Any violation of Section hundred
by any applicant for a permit subjects the eppllcam to
a civil penalty of not more men live hu ere employees
dollars with
wag): WOOD SHAKES
❑I,as owner of the property,or to employees with wages as their sole compensation,will do ❑
sio work,and the structure is not intended or offered for sale(Sea owner
of Business and builds
or
Cade:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
improves tenon,and who does such workhimselffor or through his own employees,provided that ❑
such improvements are not intended or ow offered for sale.g,however,the building pr Or improvement
notsold bull orimneye for purpose
sme owner-builtler will have the burden of provinglethe tlltl 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(See.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.
E]I am exempt under Sec. ,S&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:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued, I Seismic
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of [[[ / //� 7Dthe Labor Code,for the performance of the work for which this permit is issued.My Workers Total 2—!;4L.
Compensation Insurance carrier and Policy number are:
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N
(This section need not be completed it the permit is for one hundred dollars($100)00)or less.) —
I certify that in to 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 Law.of Cali- All roofs shall be inspected prior to any roofing material being
fornia. ^^^^ installed. If a roof is installed without first obtaining an
Date �—O Applicant e C` inspection,I agree to remove all new materials for inspection.
NOT CE TO APPLICANT.
If.after
making lutlb
sub ecct to t oerCompensaprviions Of the Labor Code,you msforthwithcomply Applicant understands and will comply with all non point
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 state laws relating m building construction,and coverings to be Ss"&r 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, `� V
• judgments,1the grancosts and expanses which may in any way accrue against said City in consequence SIGNATURE OF APPLICANT DATE
the cg of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE Z 'L� INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE'COPY