99110130 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
left DAYS FROM LAST CALLED INSPECTION.
• BUILDING
/o to ADDRESS
DI � /�
ILQ e, RESIDENTIAL COMMERCIAL OTHER
OWNER'S
. 1 ♦, ,,o ,� ! HAZARDOUS FIRE AREA
NAME �'�1�� VL7lT }� SES ❑ IIyess Iunderstandthat Class A
W oot assembly srequired.
NO ❑ Initial LC.B.O.H
ADDRESS hyo \ EXISTING ROOF COVERING
PHONE t/ (Q — —16-7, NUMBER OF EXISTING COVERINGS y
CONTRACTOR'S r A [1 L c
NAME4ZL�.W \ TO BE REMOVED TO BE RETAINED
ADORESSf�'l it•` S QOw c� G�—`\ TYPE OF ROOF COVERING
CITY 8 ZIP / ` 2. 1
f/ !`F}�( �j —1 ^-� EXISTING
PHONENCM `� � / 1 BUILT-UP ROOF
LICENSE
NUMBER ASPHALT SHINGLES ❑ ..
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Cotle,and my license is in lull force and
effect.
�-3� t'I 15 -Z09 WOOD SHINGLES
Cl
License as^� Llc.Number
Contractor . t S >I't OTHER(SPECIFY) T��
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following axon. V
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,purl or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions jn FLNOV
of the Contractor's License Law(Chapter 9(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 SHING ❑ (tet
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)J: WOOD SHAKES91 1999
I,es owner of the property,or my Employees with wages as their sole compensation,will dothe work,antl the structure is not intended or offered for sale(Sec.7044,Business antl Profes.
sions Cotle:The Contractor's License Law does not apply to a"owner of property who builds or WOOD SHINGLEimproves thereon,and who does such work himself or through his own employees,provided thatsuch 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(SPECIF -
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.71 Business and Professions Code:The Contractor'.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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declaration:
[:11 have and will maintain a Certificate of Consent to soli insure for Worker's Compensation, 1 t� ��q `� �� Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Seismic
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of r'� \
the Labor Cotle,for the performance of the work for which this permit is issued.My Worker's I�-f
camps non Insurance carrier e p Policy no bar are: Total /c-/�L_L'�l—
DO rder) re rI Policy Noi r_T 6327-6 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXME PTION FROM WORKERS'
COMPENSATION INSURANCE IN C.p /J
(This section need not be completed if the permit is for ono hon red sitars($100)or less.) Fig
f certify that in the performance of the or which his permi is as eq I shall not employ
any person in any manner so as to boco aab et to t Workers o ensalion L sof Cali. All roofs shall be inspected prior to any roofing material being
forma.` installed. If a roof is installed without first obtaining an
Date \��— I'`j App;;eEn, inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making is Certificate of Exemption,you should became Applicant unders and will comply with all non point
subject to the Workers'Compensalion provisions of the Labor Code,you must forthwith comply P Y P
with such provisions or this permit shall be deemed revoked. Ce regulatl0 s.
f certify that I have read this application and state that the above information is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and II r of covering to b Class` or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for im
spection purposes. n�
(We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence S AT E OF APPLICANT DATE
of the granting EI 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