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APPLICATION FOR CITY OF CUPERTINO
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
q RESIDENTIAL COMMERCIAL OTHER
OWNER'S / HAZARDOUS FIRE AREA
`� / ��®® �,, YES ❑ It yes-I understand that a Class A
NAME //1/P S (�l/ a�S. hadl assembly is required.
NO ❑ Initial I.C.B.O.p
ADDRESS ( % —rL���`e- �`�- ✓r EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRAC R'S
NAME TO BE REMOVEDt TO BE RETAINED
ADDRESS ��// p TYPE OF ROOF COVERING
CITY&ZIP �77 e�-�.�o,S �� S� /S��Z EXISTING
PHONE G/71 ! 777 BUILT-UP ROOF rte'
LICENSE
NUMBER ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
thereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Code,and my license is in lull force and
effect' '� WOOD SHINGLES
License Clas -7D—C-20 Lic.Number O a O O
Date a Contracmr� t+ S S wd OTHER(SPECIFY)
OWNER-BUILDER DECLARATI PROPOSED
I hereby affirm that I am exempt from the Contractors License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to Y
construct,alter,improve.demolish,ormpairany structure,priortoits issuance,also requireslhe BUILT-UP ROOF
applicant for such permit to lila 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 Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGI FS ❑
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than live hundred dollars($500).): WOOD SHAK"IS I /_<J\ I❑I
❑I,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 Proles-
siona Codo:The Contractor's License Lew does not apply to an owner of property who builds or WOOD SHIN �1
improves thereon,antl who does such work himself or through his own employees,provided that 1\0�
such improvements are not intended or offered for sale.If,however,the building or improvement 2 A
I.soltlwithin one year of completion,the owner-builder will have the burden of proving that he did OTHER(SP IFY) i7
not builtl 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 Contractor's License Law does not PROVIDE I. .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.INSTAL 1ONSPP.E-
❑I 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 following declaration:
Fj I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, - r/� Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this .G// �(�V
permit is Issued. '
01 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of Seismic
the Labor Code,for the performance at the work for which this permit is Issued.My Worker's 0 KS Total r
Compensation Insurance Carr'or and licy number are
Carrier Policy No.l[VN��nrO 9d7�/ PERMIT AUTHORIZATION DATE
CERTIFICATE OF (EMPTION FROM WORKERS'
COMPENSATION INSURANCE ( 100.0 r
(This fy that i need not be completed it the "mil is for one hundre Ilan 5100)or less.) —��ex-aV1 fp—AF
I certify that in the performance of the k to which this permi Q I shell not employ
any person in any manner so as to becom "Lice Ito thew em. ompensation Laws Cali- All roofs shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date Applica inspection,I agree to all new materials for inspection.
NOTICE TO APPLICANT: 0,alcor ma his Certificate of Exemption,you should become q licant understa ds and ill comply with all non point
subject to the Workers'Compensation provisions of the Labor Cotle,you must forthwith comply
with such provisions or this permit shall be deemed revoked. ou a regulations.
I certify that l have read this application and slate that the above information is correct.l agree
to comply with all city and county ordinances and state laws relating to building construction,and All to ICOV ings to aSS16orb her.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes. I (���-
(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 GNATU E OF APPLICANT DATE
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