99110176 (2) g9i� o�7(�
APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IIF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS `J�/
RESIDENTIAL ` COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME C�T7llJj�RC1 roof assembly is required.
�/ NO E] Initial I.C.B.O.q
ADDRESS /9C� 11��«Q� --�'IY7 EXISTING ROOF COVERING
PHONEO — NUMBER OF EXISTING COVERINGS
CONTRACTOR'S 7-6
r] / TO BE REMOVED TO BE RETAINED
NAME �ef �l/'K/�_���7n-moi f/S'_/T u�.�
CADDRESSITY&Z P G 7 7 /t-�tiKf' ST /,//Z TYPE OF ROOF COVERING
p EXISTING
PHONE �d� / 717-4 7 72 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. WOOD SHINGLES ❑
License Class Lic.Number_J 2-0 O
Date /L-3/ _� Contractor rr OTHER(SPECIFY)
theCoOWNER-BUILDER DEC's Lice ON PROPOSED /
hereby affirm that t am exempt from the e:Contractor's License Lew for the following reason. !'
(Sec.7ct,alt Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve,t demolish,Si 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 V
of the ss and
License Law)or that 9 is exempt
with Section 7000)of Division 301 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 penally of not more than five hundred dollars($501 WOAD SHAKES
I,as 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 Profits.
sions Code:The Contractors License Law does not apply to an owner of properly who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that ►Io1, ❑
such improvements are not intended or offered for sale.ll,however,the building or improvement NO V ^
is sold within one year of completion,the owner-builder wi l l have the for mon of proving that he did OTHER(SPECIFY) �71n
not build or improve for purpose of sole.).
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. twORT N=_
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. INSTALLATIO _SPE
I am exempt under Sec. ,B&P.C.for this reason
OwnerData
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
Fj I have and will maintain a Certificate of Consent to self-insure lar Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for me performance of the work for which this
permit is issued.
E]I have antl 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 7 > r
Compensation Insurance,C,arryier an Policy number are: ) ��/pp Total ` ��
Carrier ` 'e/"z 0 Policy No.WJ1'L/ 3bLTD� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE IN CL]
(This section need not be completed if the permit is for one hundred dollars($100) e J
I Certify that in the performance of the work for which this a hundred
's issued,I shall n 1 em toy
any person In any manner so as to become subject to the Work C pensati La alb All roots shall be inspected prior to any roofing material being
lurine. ailed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should became Applicant understan d will comply with all non point
subject to the Workers'Compensation provisions of the Labor Cade,you must forthwith comply PP P y P
with such provisions or this permit shall be doomed revoked. S 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 11 ROD coverings 10 eC SSS Ier.
hereby authorize representatives of this City to enter upon the above-mentioned property for in-
spection purposes.
(Wo)agree tos save,Indemnify and keep harmless the City ai Cupertino against liabilities, `7
ofthe gran costs and expenses which may in any way accrue against said City in consequence
of the granting of This permit. SIG RE OF APPLICANT DATE
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