R 5999 (2) PERMIT R_ rJ 9 9 9
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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
a0a85- ao /4S r1S C,-I, RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
NAME 30£ 7U t V YES ❑ If yes—I understand that a Class A
roof assembly is required.
t NO ❑ Initial I.C.B.O.M
ADDRESS J3_oq12:nG(�wr[scb�. E- EXISTING ROOF COVERING
PHONE U — 7 6 N— Z /6 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S t /�
NAME J O Y N KytiI'LL TO BE REMOVED TO BE RETAINED
ADDRESS (f /— TYPE OF ROOF COVERING
CIN 8 ZIP OZ 3 l7 �'PM V 1 F w '�11 f S��
EXISTING
PHONE 'T' / 8�- b3v - 33 BUILT-UP ROOF
LICENSE
NUMBER 612 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
(c
1 hereby inion that em Business
licensed under fessprovisions of Chapter 8(commencing with Sectionand WOOD SHAKES
7000)of Division 3 0l the Business and Professions Coda,and my licence 19 In lull force entl
affect.
c 43-C-3P / 3 WOOD SHINGLES ❑
Llcenae Claae Llc.Number b/
Dela Contractor
OTHER(SPECIFY) ❑
OWNER•BUILOER DEC.L/t ATION 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
construct,alter,Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOFE]applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions '
• of the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is exempt therefrom and the deals 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($500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their sole compensation,will do ❑
the work,and the structure Is not Intended or offered for sale(Sac.7044,Business and Profes.
sions Code:The Contractor's License Law does not apply to an owner of property who builds or
rWOOD SHINGLES El
thereon,and who does such work himself or through his own employees,provided that
..on Improvements are not Intended or offered for sale.If,however,the building or Improvement
is sold within one year of completion,the ownenbullder will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec,7044,Business and Prolessiona Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improve$thereon,and who contracts for such projects
with a contractor(°)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
[ I am exempt u r ,B 8 P.C.for this reason
Owner D0i0 APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the lollowlng declaration:
❑t have and will maintain a of thei Lab of Concent to sag-Insure for Worker's Compensation, //� ,S / Building/ r v�
as provided issued. Section 3700 cl the Labor Cotlo,for the performance of me work/or which this �^y (/(
permit is issued. / Seismic /, /O
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of [/ / / O 0 / 0
,the Labor tion I sur the performance of the work for which this permit Is Issued.My Worker's 0
Compensation Insurance carrier anePolicy number are: Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCC
(This section need not be completed If the permit Is for one hundred dollars($10o)or lees.)
I certify that In the performance of the work for which this permit is Issued,I shall not employ V F
any person In any manner so as to become subject to the Workers'Compensation Laws of Call. All roofs shall be inspected prior to any roofing material being
f°rale. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I afire tiremove all new materials for inspection.
NOTICE TO APPLICANT; II,after making this Certificate of Exemption,you should become
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply Applicant upd9s and and will comply with all non point
with such provisions or this permit ahallIbe doomed revoked, source regula rD
I certify that I have read this application and state that the above Information Is correct.)agree ,,�(
to comply with all city and county ominancasand state laws relating to building construction,and All roOfC g e iE''or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. .t• ,��J Qp
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, .1411 ! J
judgments,coats and expenses which may In any way accrue against said City In consequence
• of the granting o1 this permit. SIUKATUPEOF 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY