99110171 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO IN
INSPECTION DIVISION PERMIT 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
/0679 RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
/ _ -//A /A/ I YES ❑ If yes-1 understand that a Class A
NAME L Jas ,(SWC/ 14,OT$ roof assembly is requiretl.
1 NO ❑ Inlhal LC.B.O.q
ADDRESS—/9 ga10 c/r�!/ecdov� EXISTING ROOF COVERING
PHONE D 7 2, NUMBER OF EXISTING COVERINGS Cl,
CONTRACTOR'SI� RI44S TO BE REMOVED
NAME-ii Ci.- CIJI
! Ofn�L w/G Ji/S TO BE RETAINED
ADDRESS C�"'� /1 _/` TYPE OF ROOF COVERING
clrvazlP��1 QK�I7 7�� -?✓ vrs ll Z EXISTING
PHONE � ( [ I -� 7 L 7 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 lull force and
affect' //` Q WOOD SHINGLES ❑
License Clasat, 9Lic.Number 2.0 D
Date 42 — 3!-OD Contractor - I-y OTHER(SPECIFY)
OWNER-BUILDER DECLARATIO PROPOSED
I hereby affirm that I am exempt from the Contractor's License Isco for the following reason. T
(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 ROO �V]LwO
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 I Q
Business and Professions Code)or that he is exempt therefrom and the basis for rho alleged ASPHALT SHI rLES ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to IL/
a civil penalty of not more than live hundred dollars($500).): WOOD SHAK NOI/
01,as owner of the property,or my employees with wages as their sole compensation,will da YY Q (� D^� '
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Proles- 4 47
sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHIN L S
improves thereon,and who does such work himself or through his own employees,provided that
such improvements aro not intended or offered for sale.If,however,the building or improvement p,
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPE El
not not build or improve for purpose of sale.).
I]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.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a corrosions)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
I]1 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 pequry one of the following declaration: �
I]I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, I (—L/— 7��(/(/ Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this , I
permit is issued.
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of ^ ISeismic j
the Labor Code,for the performance of the work for which this permit is issued.My Workers �� A C Total /tl •
CompensaI n Insurance carrier and Policy number are:
carrier rE Policy No�,�801o322_4/ PERMIT AUTHORIZATION DATE
CERl OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ ^ ' _ ��
(This section need not be completed if the permit is for one h tlr dollars($too)or less.) �V1—„��
I certify that in the performance of the work for which Nis per it is uetl. shall not employ
any person in any manner so as to becom u act to th orker bensation law of Cali- All roofs shall be inspected prior to any roofing material being
forma. 1 installed. If a roof is installed without first obtaining an
Data-�(_/i � App;;ca , inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become A 'can'
understa s a will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must lorthwith comply
with such provisions or this permit shall be deemed revoked. OUr a 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 All rO fDDIV IngStrbetter.
hereby authorize representatives of this city to enter upon the above-mentioned property lot in.
sp epurposes.
(WI I — Z�x a
(We))agree to save,indemnify and keep harmless the City of Cupertino against liabilities, W`dOV / /
(71
judgments,casts and expenses which may In any way accrue against said City in consequence IGNATU RE OF APPL CANT 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
OFFICECOPY