99110178 (2) 1 S
2 15=1
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES W WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
-r RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
.(, YES ❑ If yes-I understand that a Class A
NAME /J/J• roof assembly is required.
p �J �`{ NO ❑ Initial I.C.B.O.#
ADDRESS Z 9o2O (O�«"eGr.�C. - EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /T�'-�'
CONTRACTOR'S
// /^ TO BE REMOVED TO BE RETAINED
NAME
ADDRESS
8 ZIP l0?� K�IN<)S �r TYPE OF ROOF COVERING
CITY EXISTING
PHONE 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
effect.
3� Zd WOOD SHINGLES ❑
License Class�- � Lic.Number
�1—�)_yr] � ���5 S OTHER(SPECIFY)
Date, OWNER-BUILDER
OWNER-BUILDER DECLARATION PROPOSED Sez
L
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 d
applicant for such permit to file a signed statement that he is licensetl 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 hundrbyany applicant for aPermit subjects the applicant to D ��
e civil,as
of not more than five by employees
yeesdollars(h wag): WOOD SHAKES
❑1,ee 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. NOV 9
D
signs Code:The Contractor's License Law does not apply to an owner of property who builtls or WOOD SHINGLES 'IArO9
Improves thereon,and who does such work himself or in rough his own employees,provided that
such improvements are not intended or offered for sale.If,however,the building or improvement J
is sold within one year of completion,the owner-builder wl 11 have the burden of proving that he did OTHER (SPECIFY) ByElnot 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 Contractor's License Law does not PROVIDE I.C.B.O.REPO TNOt-
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractorls)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 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: �
�� Q
[DI have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, '1_ - / � Building
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this
permit is issued. Seismic
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 7
the Labor Cotle,for the performance of the work for which this permit is Issued.My Worker's {.I Tota
CampensaI. Insurance c rrie nit Policy number are: G��/
carrier�;z; � �'.� Pokey N �` ,M432 -0 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ r/
(This fy that
need not be ante of the
if the permit is for one hunpermit k tl ar $100)or lasso r i�
1 person
Thal ny the performance of the war or hich this permit i sued, hall not employ
any person In any manner so as to become object o the Work re'co don Lawe call- Ali roofs shall be inspected prior to any roofing material being
fornia. _ installed. If a roof is installed without first obtaining an
Date Appllcan inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after maki is Certificate of Exemption,you should became Mai nds nd wi om I with all non ofnt
subject to the Workers'Compensation provisions of the Labor Cotle,you must forthwith comply P y Pwith such provisions or this permit shall be deemed revoked.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 antl state laws relating to building construction,end eclass" or bettehereby authorize representatives of this city to enter upon the above-mentioned property for imspathe)purposes.(We)agree m save,pensesity antl keep harmless the City of Cupertino against liabilities,judgments,costs and expenses which may in any way accrue against saitl CitPLICANT 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