99080212 35 0 2-7-
PE
PE
APPLICATION FOR CITY OF CUPERTINO NUMBE
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
1B0 DAYS FROM LAST CALLED INSPECTION.
' BUILDING ADDRESS
Cs( �/
CD cJ ! RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ II —I understand that a Class A
u
NAME �� /\ / /1�� Xf essemDly is required.
NO Initial I.C.B.O. Y
EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /J .r� n
NAME?QL4 MD C_ox S RII`klaoll 4��IC BE REMOVED TO BE RETAINED
ADDRESS lJ,D�BCt�f 9�3 H fLL B�AE C� O3D TYPE OF ROOF COVERING
CITY&ZIP r s� �7 �/p EXISTING
PHONE ✓ O 9 ( ( � BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES - ❑
COD aaDECLARATION -
I hereby sitter that I son e with sed under proArnwof Chapter B(commencing Section WOOD SHAKES
]000)of Division 3 of the Business and Professions Code,and my Ikense Is In full brce and
all
3 7 C WOOD SHINGLES
License Claes� Uc.Number
Date /I' 3 / —ZO�� contract OTHER(SPECIFY)
Opt fr. theC R EC RA PROPOSED
hereby affirm that em exempt from the Contractor Lb se Law for the lolbwing reason.
(Sec.7031.5,Business and Profession,Cow: Any city w county which requires a permit to
construct,after,Improve,demolish,or repair any stmcture,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
app!1=1 lar such permit to Hie a signed statement that he is licensed pursuant to the WpAid na
of the Contradars Licmee Lew(Chapter 9(commendng with Section]000)N DiWslon 3 N the
Business and Professk>ns Code)or that the Is exempt therefrom and Ne basis for the alleged ASPHALT SHINGLES ❑
• exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a avll penalty of not more than five humred dollars($50D).):
E]1,as owner of the property,or my employees with wages a,their sole compeneetlon,will do WOOD SHAKES ❑
the work,end the structure U not Intendetl or offered for sale(Sec.7044,Business and Protea. ,
sions Code:The Control License Law does rot apply to an owl of property who builds or WOOD SHINGLES -
Impraws thereon, lld awnd uch dean swork htrneeH or through this own empoyans,provided that ❑
such Improvements are Mlateral or offered for sale.ILwever,hothe building or Improvement L/
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ^�
not build or Improve for purPota of sale.).
I,as owner of the proper)µam exclusively contracting with Ikensed mittractom to construct
the project(Sec.7044,Business and Professions Code:The Contractors Ucerae Law does not PROVIDE LC.B.O.REPORT NO.
appy to an owner of property who builds or improves thereon,and who contracts for such projects
with a mnvactodid licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sac. ,B&P.C.for this reason
Orator Data
WORKER'S COMPENSATION DECLARATIOfJ APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under penelty of perjury we of the following declaration: _
❑I have and will malnrain a Canlficate of Consent to swM nsure for Workers Compensation, ^
as provided for by Section 370D of the Labor Cala,for Me,pedme fairBUlldln
arance of thwork which this !/ D �v fr1g°lI
permit is issued. SBIS1C 1-(JO
❑1 have and will maintain Worker's Compensationa work
Insurance,as required I u .My orio of
a a, c.
Me Labor Cotle,or the performance of the vwrk for which this permH Is Issued.My Workers
Compensat race carrier antl Policy number anre: - Total
Camer �� y�l/V G PmkyNo. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ -
(TNe section need non nd completed it the permit Is for one hundred dollars($100)or less.)
I cenfly 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'Compensation Laws of call. All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Date Applicant inspection,l agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,alter making the Celulos a of Exemption,you ahould became Applicant understands and will
subject to the Workers'CompenaLabor Code,provisions of the LaCode,you mural fortlrwith comply PP comply P Y with all non point
with such provisions or 1N,permit shall be deemed revoked. source regulations.
I certify that I have read this application and state that the above ldbrmation is correct.I agree
to comply with all city end county ordinances and state laws relating to building constnoflon,and A
llBrings to be Clas or better
hereby aul representatives of ft is city to enter upon the above-mentioned property lar In-
specuon purposes.
(We)agree to save,Indemnify and keep Internal the Cly of Cupertino against IiaWltles,
oufdighe enlgrae,r p r althis expeperm�which may In any way accrue against saki City In consequanceT 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
OFFICECOPY