00040121 26 - Y3 - 01
PE
APPLICATION FOR CITY OF CUPERTINo NU
INSPECTION DIVISION - PERMIT EXPIRATION
' REROOF PERMIT (406)777-3228 - PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• • - 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS AADDRESS 1 {/
AMU{P.0 D,- RESIDENTIAL COMMERCIAL OTHER
OWNER'S _ HAZARDOUS FIRE AREA
, T //' YES ElIf yes;-I understand that a Class A
(�'
NAME �hILLQ JLYVI ) CIP X) - NO ❑ roof assembly is required
nitial LC.B.O.W
ADDRESS A)376 -Aml J,r EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS SIMI -;0 S-y�--
PHONE
CONTRACT Q R'S c ` '
(/� ��� N1 TO BE REMOVED�Z�� TO BE RETAINED v�'
NAME /�TA�-li CCPa]f P '/bU f kifmQ
TYPE OF ROOF COVERING
ADDRESS 7 r� J ) A N l �• ��T
CITY 8 ZIP�d y ^^ y !t � � L'"� I 7 EXISTING
PHONE .(Y1£7 SVg -I BUILT-UP ROOF S
CENSE
NUMBER 6 r/ ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION O
I hereby affirm that I am licenseduntler provisions of Chapter 9(commencing with Section WOOD SHAKES - O
7000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect WOOD SHINGLES ❑
License Class (✓�� -tic.Number_7lQ_L
Date
Q�3o%ID Con . OTHER(SPECIFY) El _
tractor
OWNER-BUILDER DECLAR 'N PROPOSED
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,attar,improve,demolish,or repair any structure,priors,its Issuance,also requimsthe 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 Prolossions 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 penalty of not more than five hundred dollars($500).1:
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes.
sions Code: The Contractor's License Law does not apply to an owner of property who builds 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 safe.It,however,the building or improvement
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 purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. 7� _
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. - ,B 6 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,lot the performance of the work for which this
permit is issued. Seismic
have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the abor Code,for the performance of the work for which this permit is Issued.My Worker's Total
Compensation Insurance carrier end1Poh�y number are: 0 QQ 3
Carrier dwyoylC4yl�,-•�iWloyf Policy No. 0023(Y700 PERMITAUTHORIZATION DATE
,CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATION INSURANCE N.C.
(This section need not be completed it the permit is for one hundred dollars($100),r less.l
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 became subject to the W kers Compensation Laws of call- All roofs shall be inspected pri6ol rooting material being
found. installed. If a roof is installed without first obtaining an
Date Applicant g
o Qv JA inspection,I agree to remove all new materials for inspection.
' P _
NOTICE TO APPLICANT: If,after making this 0 rtificate of Exemption, ou should become A llcant understands and will Comlith with all non olnt
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. source regulations.
I certify that I have read this application and State that the above information is correctI agree
to comply with all city and county ordinances and slate laws relating to building construction,and All roof coverings t 4)e lass"C"Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in- / /
spection purposes. & /tea
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, 0
judgments,costs and expenses which may In any way accrue against said City In consequence SIGNATURE O P AN TE
of the granting of this permit.
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 - /