00020014 CP-2 3Z� S a� 5 bobO-Q)
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R-
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
WI DANSS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
z1?3
ES0MP_C 4Reo
RESIDENTIAL COMMERCIAL_OTHER
OWNER'S ^^ / HAZARDOUS FIRE AREA
NAME U ,— /C' 1 VES 0 II yes—I understand that a Class A
roof assembly is required.
_ t / / NO ❑ Initial I.C.B.O.#
ADDRESS—/3& C t DCLycp. is �r Vie(,-) EXISTING ROOF COVERING
PHONE 65O 9/ -3�3 C) NUMBER OF EXISTING COVERINGS `
CONTRACTOR'S
TO /'v•2 r TO BE REMOVED _TO BE RETAINED
NAME-0 .k...�
ADDRESS rZ % R / `� TYPE OF ROOF COVERING
CITY&ZIP- 3g ` ,J ✓`I�'�b e coq e r R �1 ' EXISTING
PHONE BUILT-UP ROOF
LICENSE 77 '7 ?
NUMBER LCr [ .J ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Division
3 of the Business and Professions Coda,and my license Is In full torso and
enact. WOOD SHINGLES vi
4464
License Class L Lic.Number Z� 7 15 I
Date ?—Zt7 Contractor r OTHER(SPECIFY) ❑ ��
OWNER-BUILDER DECLARATION 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 ROOF
applicant for such permit to lila a signed statement that he is licensed pursuant to the provisions ❑
. of the Contractors License Law(Chapter B(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 civil penalty of not more than five hundred dollars($500)):
E]1.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(Sac.7044,Business and Proles-
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 (nI
such improvements mems aro not intended the
offered for sale.If,however,the building of Improvement OTHER(SPECIFY) d��l+l��
n tsold build
one year ofcompletion.the Owner-builder will have the burden of proving that he did
not buiM 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.
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.
C]I am exempt under Sec. ,B&P.C.for this reason
owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATEVALUATION PERMIT FEE
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, BUlldingt�_
as provided for by Section 3700 of the Labor Code,for the Performance of the work for which this
permit is issued. Seismic
♦ it'O
❑ have and will maintain Worker's Compensation Insurance,as required by Section 3700 of !!!! L CCC.........
the Labor Code,for the Performance of the work for which this Parrott Is issued.My Worker's
Compensation Insurance carrier and Policy number are: Total lfwo
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 .r
(This section need not be completed if the permit Is for one handraildollars($100)or less.) / Z-o O-b V
I certify that in the performance of the work for which this permit Is Issued,I shall not employ - s�
any person in any manner so as to become subject to the W kers'Compensation Laws of Call. All roofs shall be inspected prior to any roofing material being
(amts. installed. If a roof is installed without first obtaining an
Data -2--L-Ce) Applicant inspection,I agree to remove all new materials for inspection..
NOTICE TO APPLICANT: ll,after making thOVOertificato of Exemption,you should become Applicant understands and will I with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP comply Y P
with such provisions or this permit shall be deemed revoked, source regulations.
I certify that I have read this application and slate that the above Information Is correct.I agree
to hereby authorize
ze rep andese county ordinances to enter
laws head above-mentioned
property
and All roof cover SS e "Or better.
hereby authorize representatives of this city to enter upon the abovemontionetl Droperty for im
spection purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, —'L—
judgments,costs and expenses which may In any way accrue against cad City In consequence
of me granting of this permit. IGD�ATURE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
O FFICE'COPY