5036 PERMIT R_ 5 0 3 6
APPLICATION FOR CITY OF CUPERTINO NUMBER
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
�� q y� �a�.�. c�—
RESIDENTIAL�COMMERCIAL OTHER
OWNER�s HAZARDOUS FIRE AREA
\ YES ❑ if yes–I understand that a Class A
NAME • 0..J roof assembly is required.
NO ❑ Initial I.C.B.O.#
ADDRESS ��— EXISTING ROOF COVERING
PHONE `�'d�� Z S �' � 7 Z� NUMBER OF EXISTING COVERINGS •
CONTRACTO _
— ��J „ _ _ � C� TO BE REMOVED TO BE RETAINED
IVAME r•wY`�
ADDRESS���-�V� �� Q„f_ ''JLp�__ „��}. 9,/�- �PE OF ROOF COVERING
CITY&ZIP T� �� Jj ���r� �r'� EXISTING
��1a�7 7 0 -C�3 6 Z- /
�
PHONE BUILT UP ROOF ��
LICENSE � �`f ASPHALT SHINGLES ��w/�
NUMBER G
LICENSED CONTRACTORS DECLARATION �
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
�000)of Division 3 of the Business and Professions Code,and my license is in full force and
e�tect. WOOD SHINGLES
License Class �� � Lic.Number �� , ❑
Date
� —contractor � OTHER(SPECIFY) ❑
OWNER-BUILDERDECLARATION ��� � ��pF�
I hereby affirm that 1 am exempt from the Contractor's�icense Law for the following reason. PROPOSED Fy�
(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 ❑
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 civii penalty of not more than five hundred dollars($500).): WOOD SHAKES ❑
❑I,as owner of the property,or my employees with wages as their soie compensation,will do
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes- �0.
sions Code:The Contractor's License Law does not apply to an owner of property who bullds or WOOD SHINGLES ❑
improves thereon,and who does such work himself or through his own employees,provided that �
such improvements are not intended or offered for sale.If,however,the building or improvement � /► j1
is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) � l.�fJ
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 Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. 93
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�aw. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
owner �ate APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby aftirm under penalty of perjury one oi the following declaration: r
❑I have and will maintain a Certifica[e of Consent to self-insure for Worker's Compensation, �� Building �
as provided for by Section 3700 of the Labor Code,for the pertormance of the work for which this / /� / /
perm' ' issued. � ���f,L �V/ q(p 6 $eISI711C �{�
ave and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the abor Code,for the pertormance of the work for which this permit is issued.My Worker's Total
Compensation�I�npsurance carrier end Po�licy number are:
carrier�Q-�"� ��1'��1'� L7�12— Policy No.��` �d�� PERMIT AUTHORIZATION DATE
� CERTIFICATE OF EXEMPTION FROM WORKERS' �
COMPENSATION INSURANCE N.C.❑
(This section need not be completed if the permit is for one hu�dred dollars($100)or less.)
I certify that in the performance of the work for which this permit is issued,I shall not employ
any person in any manner so as to become subject to the Workers�comPe�set�o��eWs or car- All roofs shall be inspected prior to any roofing material being
f°�"'a. installed. 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 become A licant understands and will com I with all flOfl 011lt
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PP P Y P
with such provisions or this permit shall be deemed revoked. SOUfC@ f@gU�3tl0(1S.
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 roof cov Itl e class" ��or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. A // /
(We)agree to save,indemnify and keep harmless the City ot Cupertino against Iiabillties, L •(�
judgments,costs and expenses which may in any way accrue against said Ciry in consequence SIGN URE OF PPLICANT DA
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECT�ON: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OS�HA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION