00020016 C 326 6 �' oliSS
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 180 DAYS OF PERMIT ISSUANCE OR
. 180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
2 ! 2 3 0 RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
/_/U p�u C q' YES ❑ If yes—I understand that a Class A
NAME L� CC L !i roof assembly Is required.
yam/ p 9 NO ❑ Initial I.C.B.O.q
/ 11 Vrecj EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
NAME Y 1 1T
.(A id 1� 2 `'� TO BE REMOVED TO BE RETAINED
ADDRESS Z � �� e� TYPE OF ROOF COVERING
CITY 8 ZIP_
(� EXISTING
PHONE dlop•o 36?_ it I 7 BUILT.UP ROOK [T—
LICENSE
622- 7 -31 ASPHALT SHINQLE�
NUMBER ®l
LICENSED CONTRACTORS DECLARATION
hereby inion that I am licensed under provisions of e,and B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is in lull force and
affect.
C� 39 fez? 7 31 WOOD SHINGLES ❑
License Class Us,Number-
Z-2—p� 0, l'_ (Z OTHER(SPECIFY) ❑
Date Contractor
OWNERTBUILDER DECLARATION PROPOSED
I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Cade: 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 Elapplicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractors License Law(Chapter 9(commencing with Section 7000)of Division 3 of the
Business and Professions Cade)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES Elexemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not mora than five hundred dollars($501 WOOD SHADES
[3I,as owner of the property,or my employees with wages as their sale Compensation.will do ❑
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 Elim roves 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 ^
Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER (SPECIFY) C C
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 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 admissions)licensed pursuant to the Contractors License Lew, PROVIDE MFGR.INSTALLATION SPECS.,
E]t am exempt under Sec. ,B 8 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,for the performance of the work for which this
permit is issued. u (� Seismic
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700rs J 7 11 /'�^ .�
the Labor Code,for the performance of the work for which this permit is Issued.My Workers "? 1 `
Campen��saeAtItlon Insurance carrJ�'Rl[e7tl�Policy/number ere: - Total V
Carrier/�;t�'fCf.N 6e)n policy No[,) PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not be completed if the permit is for one hundred dollars($100)or less.) n G d to.y
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'Comperi Lawa of Cali- All roofs shall be inspected prior to any roofing material being
fornix. 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: 11,after making this lKenificato of Exemption,you should become Applicant understands and will comply with all non oral
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 makes. source regulations.
I certify that I have read this application and state that the mauve information is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof covert n sto be class" or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes.
(We)agree to cavo,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence
of the granting of this permit. IG URE 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