00020132 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
j WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
(� BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ It yes—I understand that a Class A
NAME (]yl/x� t Bassani is required.
/ �(/ ) o(�� NO Initial I.C.B.O.H
ADDRES96�? 5 va"`"+"• �/Lu.�-� �`'h+^"'�I�uCL. LZ'�� EXISTING ROOF COVERING
PHONE 733-Z 7 NUMBER OF EXISTING COVERINGS If
CONTRAC S �^ _ •o
NAME _ / �• TO BE REMOVED TO BE RETAINED ,
ADDRESS TYPE OF ROOF C RING
CITY 8 ZIP cf-"" C��YI VCOI 7u.Y.+9000Geb EXISTING
PHONE BUILT-UP ROOFLICENSE
NUMBER 2 OU ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby allirm 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 full force and
effect' WOOD SHINGLES
License Classs G39 Lic.Number 7L ZOO El
Date W30101 Contractor OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARE rION 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
1 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 Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES�II
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to y C p
Bi �❑ I
a civil penalty of not more than five 01.):
e hundred dollars($50WOOD SHAKES `U
❑I,as owner of the property,or my employees with wages as their sole compensation,will do D
the work,and the structure is not intended or offered for sale(Sec.7044,Business and Proles- Fp ooO
ons 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 B
such improvements are not intended or offered for sale.II,however,the building or Improvement Y
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 ler purpose of sale.).
C]1I,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 LC.B.O.REPORT NO.
apply to c ntownerof property who builds orimproves thereon,and who contracts for such projects
with a c m ex m pt)ulicensed rSe pursuant to the Contractor's License Low. PROVIDE MFGR.INSTALLATION SPECS.
❑I ore exempt under Sec. ,B&P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, 970 Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ' // O tl /
permit is issued. fG✓[G !LS
have and will maintain Worker's Compensation Insurance,as required by Section 37000) Seismic
thief Labor Code,for the performance of the work for which this permit is issued.My Worker's
Compensation Ins nce cern—er7and Policy number are: Total
Carrier Tl'�"A4 -- PolicyNo.Is7_/ /z-� PERMIT AUTHORIZATION 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)or less.)
I certify that in the performance of the work for which this permit is issued.I shell not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shan be inspected prior to any roofing material being
forma. L installed. If a roof is installed without first obtaining an
Date G Ou Applicant !/ inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11,after making this Certificate 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 doomed revoked. source regulations.
I 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 All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in- S� ^ 2 O
spathe)purposes. 1/moi'// 0
(We)agree s save,indemnify and keep harmless the City ai Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against seitl City...consequence SIGNATU OF APPLICANT ATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
r. 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