99110175 (2) 3l(� - `t3-- Ov(' 1l0I�S
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMB
INSPECTION DIVISION PERMTTEXPIRATION
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 -x
DS RESIDENTIAL---&COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
,�1�1 YES [D If yes—I understand that a Class A
NAME �)? .4/V✓d Zi roof assembly is requiretl.
Gyp / NO ❑ InNal I.C.B.O.#
ADDRESS— Iy xe L /'L^ EXISTING ROOF COVERING
PHONE1?962 -71
NUMBER OF EXISTING COVERINGS 12_�
CONTRAC 'S O_ (`
NAME �PCla-f!?-li /—�0�/v>•j �J VtZJe0.� TO BE REMOVED TO BE RETAINED
ADDRESS / y n CT ` TYPE OF ROOF COVERING
CITY a ZIP 6 l`-77 1 I��7- ' JJ �57;_ " ' EXISTING
PHONE 0� `l�l/ / BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm 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
affect. a� WOOD SHINGLES
License Clar Lic.Number
Date ' � Contractor eW,_-�- v OTHER(SPECIFY)
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
con struct,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 Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Code)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 live hundred dollars($500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ARECS—
[:]
thework,antl the structure is not intended or offered for sale(Sec.7044,Business antl Profes-.ions Cotle:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES
improves thereon,antl who tloes such work himself er 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) NOV not build or improve for purpose of sale.).❑I,as owner of the property,am exclusively contracting with licensetl contractors to construct
the project(Sec.7044,Business and Professions Cotle:The Contractor's License Law tloes not PROVIDE I.C.B.O. EPORT NOapply to an owner of property who builds or improves thereon,antl who contracts for such projects Bywith a contractors)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.I tL-ATfOI am exempt under Sec. ,B&P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration: Q
I have and will maintain a Certificate of Consent to sail-insure for Worker's Compensation, ' (�Z�. /% '�S(70 Building=
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this /
permit is issued. Seismic -
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 91—Ix
the Labor Code,for the performance of the work for which this permit is issued.My Workers S Total I W I t 1
Compensation Insurance car iffier an olicy number are: !.r•IL� w
Carrier �`�1' ��Y— POIicyNa.^'✓(9� 3�7'V/ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION if the per is INSURANCE N.C.
(This section need
the not be completed if the par is for one hundred otters( 100)or lasso
certify that n the performance of the work r t h this permit is sued, hall not employ r
any parson in any manner so es to becomes fact 1 the Work 'Co lion Laws of call- All roofs shall be inspected prior to ang roofing material b ing
forma, installed. If a roof is installed without first obtaining an
Date -Z� 9'�' Applicant el� inspection,I agree to remove all new materials for inspection.
NO ICE TO APPLICANT: IL after makin is Certificate of Exemption,you should become A "int understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply
with such provisions or this permit shall be deemed revoked. Ourc 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 rotating to building construction,and All to COV Ings to CI or 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, C�
judgments,costs and expenses which may in any way accrue against said Cit in consequence IGNATURE 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE'COPY