99110032 3 -75- . O in 3 R 3 �
' PERMff
APPLICATION FOR
CITY of cuPERTINo NUMBER R�.
REROOF PERMIT INSPECTION DIVISION RM (PIRAT10N
(408)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTER
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
150 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZARDOUS FIRE AREA
mak '
NAME // YES E] If yes—I understand that a Class A
roof assembly is required.
- NO ❑ Initat I.C.B.O.r
ADDRESS '5 OIL- ilk EXISTING ROOF COVERING
PHONE — 'J NUMBER OF EXISTING COVERINGS 1
CONTRACTOR'S
NAME &4a / _ TO BE REMOVED "` T ERETAINED
CITYRB P 1 ^ Ll�.
�. D �r EXISTING
PHONE 41d k M33 774v/
O
LICENSE 17
`Y•S ' r
NUMBER fJ 1 ASPHALT SHINGLES .❑ "
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcansed under provisions of Chapter B(commen I with Section WOOD SHAKES
7000)of DMsen 3 of the Business and Professions Code,and my license Is In full force and -
off�' WOOD SHINGLES
1-cense Clew>...n--L5q Uc.Number Q a xJ 3`C AO ❑
Date oonumer OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm prat I am exempt Iran the Contractor's License Lew for the following reason.
fSec.7031.5,Business and Professions Code: Any city or county which requlres a permit to
construct,after,Improve,demollah,er repair any structure,prior to Its Issuance,also
requires the BUILT-UP ROOF
apNlcant kx each permit to file a signed statement that he Is licensed pursuant to the prwleons
of the Contractors License Law(Chapter 8(commendng with Section 7000)of Division 3 of the
Business and Profeaelone Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLE � � D
exemption.Any Noletlon of Sedon 7031.5 by any°ppllcani for a permit subjects Me applicant to n -�
a civil penalty,of not more then five hundred dollars LI
❑1,as owner of the property,or my employees with wages(their Bole compensation,Mil do WOOD SHAKES NOV ° 1999
Me work,and the structure Is not Intended or offered for sale Sec.7044,Business and Pmles-
done Cade:The Contractors License Law does not apply to an owner of property who buica or WOOD SHINGLES
improme thereon,and who does such work himself or through his own employees,provided that ❑
such improements are rot Intended or offered for sale.It,however,the building or Improvement
Is sold wlthln one year of completion,the owner-builder will hem the bidden of proving that he did OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.). ny
❑I,as owner of me property,am exclusively cor mcbg with licensed contmctote to construct
the project(Sec.7044,BwInesa and Professions Code:The Corrector's License Law dose not PROVIDE I.C.B.O.REPORTNO.
apply to an owner of property who builds or Improves thereon,and who contracts for such pmjeda
with a contraaogs)licensed pursuant to me Contractors License Lew. PROVIDE I INSTALLATION SPECS.
[:]I am exempt under Sec. ,B 6 P.C.for thIs reason
Owner oats WORKER'S CCMPENSATK]N OECLARATK)N APPLICATION DATE VALUATION PERMIT FEE -
'
I hereby affirm under penalty of perjury one of me fallowing deciarabal
❑1 hem and will maintain a Certificate of Consent to sell-insure for Workers Componsstlon, Building
ea provided for by Sectfon 37W of the Labperformance of Code,for me performof me work for which this
path'"le Issued' Seismic
❑1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of
the Labor Coda,for the performance of the work for which Ohs permit Is issued.My Workers - Total
Compensation Insurance carie nd P�oi num(ber are
Canis— il�y (S`F2CJ9.In.r a,.ricy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' y
COMPENSATION INSURANCE N.C.0 - •�
(This section need rot be contlAced If me permit is for one hundred dollars($100)or leis.) /
I certify that In the performance of the work for which this penult Is Issued,I shall not empIvy
any person m any manner so as be become eab)ed to ma workere'Compensatdn Lawn of Cell- All roofs shall be inspect prior to any roofing material being
f°`m°. 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: It,after making this Certificate of Examption,you should become A Ilcant understands and will I with all non point
aublect to the Workers'Compensation provislons of the Labor Code,you must forthwith comply pp comply Y p
with such provlelons or thIs permit shell be deemed revoked. source regulations.
I cerfity that I have read this epplicatl°n and state that the movo Informal Is correct.I agree
to comply will,all city aryd county ordinances and state laws relating to building conspuction,and All roof cove ifs to be class I&better. -
hereby authorize revesentatives of this city to enter upon the above-mentioned property for In-
apemen reeea.
agree
(We)°gree s save,Indemnity and keep harmless way cc City of Cupertino agelnst consequence
of gmenta,coots and permit. s which may In arty way ocarina against Bald City In consequence
of me granting of mIs permit. SIGNATURE 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY