99090149 (2) 3 y° Z c �
'_2909p�� PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)7773228 PERMITXPIKES IF WORK IS NOT
WITHIN 180
DAYS OF PERMIT ISSUANCEANCE OR OR
1 B DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS X
RESIDENTIALZ_COMMERCIAL OTHER
OWNER'S _ HAZARDOUS FIRE AREA
NAME /�I�C�C�/' `«.ia-+�`^— YES ❑ It
assembly s requinderstand rat ed.
NO
Class A
NO ❑ Initial I.C.B.O.#
ADDRESS Qui EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME TO BE REMOVED / TO BE RETAINED
�/ G
ADDRESS L , /R� JJ �� —C�nC� TYPE OF ROOF COVERING
CITY&ZIP 7 l/ L�fv J•`F
q _ I SINESS
PHONE �� ` _ �.J 3 Z
NUCENSE MBER I h �I!S DOEN
LICENSED CONTRACTORS DECLARATION
hereby affirm that em Business
ssunder Professions
lona of Chapter B(commencing with rcecann
7000)of Division 3 of the Business entl Profesalans Cotle,entl my license le In full force entl
e
License
i /
Lcenn se Class � � Lic,Number � S
Date t0 Contractor S '
OWNER theLDER DECLARATION PROPOSED
hereby elllrm that am exempt from the Contractors License Lew for the requires
ap reason.
(Sec.7ct,alt Business and Professions Code: Any dry or county which requlree a permit to
sop Icangalter,Improve,to file asiorrepairenystructure,prior to Its Issuance.also requlreethe BUILT-UP ROOF ❑
eppllcenl for such permit to file(Capt statement that he IslicensedSectio pursuant to the Provisions the
' of the Contractor's essLicense Law(Chapter h(commencingIsexpt therefrom
Seaton]000)of Division 3 of the
Business and violation of Code)or that he a exempt therefrom end the beets for the alleged A ALT SHINGLES ❑
exemption.Anyviolationo t more
of Section 7031.5 by any applicant for a permit subject s fhe eppllcenl to
e civil penalty of not more than floe by employees
dollars($500).1: Q OD AKES ❑
❑I,as owner of the property,or my employaea with wages as their sole compenaellon,will do
the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profen- ❑��`C D•/
sions Code:The Contractor's License Law does not apply to an owner of property who builds or W IN /�
Improves 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 OTHERS CIFY) Qg
not build or Improve for purpose of sale.).
❑I,as owner 01 the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law tloes 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 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby elllrm under penalty of perjury one of the following declaration: /)��Vl
Fl have and will maintain a Certificate of Consent to sell-insure for Worker's Compensation, / O? Building Off(/ !/
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this ^^ / ('
PO
rm IS Issued. 1� y I /7 ?00 Seismic
have end will maintain Worker's Compensation Insurance,as required by Section 3700 of
the a or Code,for the performance of the work for which this permit Is Issued.My Worker's �,.t� ��
Co pen bon Inaumnce eLerrler end Polley number are: Total 0C(,LY-:�,^/
94�
Carrier �5��V�� Polity N PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WO KERS'
COMPENSATION INSURANCE N.C.O
(This section need not be completed If the permit Is for one hundred dollars($100)or lase.)
I certify that In the performance of the work for which this permit Is Issued,1 shell not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali. All roofs shall be inspected prior to any roofing material being
fornia. y/ installed. If a roof is installed without first obtaining an
Dat, 14 Applicant r inspection,I agree to remove all new materials for inspection.
NOTI E TOA PUCANr: If,after making this Cartlfie a of Exemption,you should become Applicant understands and will comply with all non clot
subject to the Workers'Compensation provisions of the L bor Code,you must forthwith comply P Y p
with such provisions or this permit shell be deemed revoked. Source regulations.
I certify with
all av9 and
county
ordinances
and d state to laws aboveting t building Is construction, ree
to and All roof cOVBpO S be Cl S"C"or better.
hereby authorize rry ese county of this cea ane ter upon
the bove- entiinn d property
f,and g
hereby authorize representatives of ihle city to enter upon the above-mentioned property for In-
sp en purposes.
(W
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
judgments,coats and expenses which may In any way accrue against said City In consequence SIGNATURE OFAPPLICANT 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