99110177 (2) otR l to
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBE
ATON
INSPECTION DIVISION
REROOF PERMIT (408)777-3'2'2$ PERMIT EXPIRESIFWORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS Y
Will 7 Q RESIDENTIAL COMMERCIAL OTHER
Ovilkil HAZARDOUS FIRE AREA
/,r /) VES ❑ If yes-I understand that a Class A
NAME f/V e 54 � w root assembly is required.
p �1 NO ❑ Imbal I.C.B.O.a
ADDRESS I / �I20 (���� f ,, EXISTING ROOF COVERING
PHONE V '� ;'(111 NUMBER OF EXISTING COVERINGS
CONTRACTOR'SO (///'` /
NAME SPc-url4v F.O�ZaN9 �f/fiC/scL TO BE REMOVED TO BE RETAINED
ADDRESS /�� �S �W �� ����1 TYPE OF ROOF COVERING
CITY&ZIP lQ
EXISTING
PHONE �71—1777 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 Code,and my license is in full force and
effect. c O �+ WOOD SHINGLES
License Cla�'2 (-- �ic.Number --7 Z0 (/J���� OTHER(SPECIFY)
Date 1 2- 7)—00 Contractor Ill-�'^ "v-"' ','A'� �`v 5
OWNER-BUILDERDECLARATION PROPOSED / cEl
7�
I hereby affirm that I am exempt from the Contractors 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
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 SHINGLE
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to 4ECS. E a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES <0I,as owner of the property,or my employees with wages as their sole compensation,will dothework,end the sbucmre is not intended ores not for sale(Sec. er of Bsiness and Proles- /01/Bionsvesth reo Contractor's License Lewtli spoorthro apply ghhownere ployedy who buildsot WOOD SHINGL 'himproves thereon,and whotlpen deco work himself or through his own employees,provided thatsuch Improvements are not intended or offered for sale.❑,have the the en ofpr o i improvement
n t ld build ori prove for purposetof rode owner-builder will have the rurtlen of proving that he did OTHER(SPE
not b 1.a or improve for purpose of sale.). \I,ec owner of the properly,am exclusively contracting with licensetl contractors to construct
the project(Sec. of pr Business antl Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.RE TNO.
apply tc ntownerof properly whobuilds orimprovesthereon,and who contracts for such protects \with a0 c m ex mrpt un e r Se pursuanuo Lha Convector's License Law. PROVIDE MFGR.INSTALLATIO�I am exempt antler Sac. ,B 8 P.C.for This reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLAHATION
I hereby affirm under penalty of perjury one of the following declaration: -
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, / I_'7 ql , 7 TO Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this / C� / /
permit is issued. _
1 have and will maintain Worker's Compensation Insurance,as required by Section 37M of �/ (� Seismic
the Labor Code,for the performance of the work for which this permit is issued.My Worker's 7 {-+ Total (W f 1�
compensation Insurance carrier nPPolicy number are: ��/.� pO,s 1
Carrier M-44-, `�`�� Policy NO.VNfyTMIf �_ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .C.❑
(This section need not be comported if the permi s for ono hundretl otters($ 0)or less.)
certify that in the performance of the work for hi h this per it is ids eq s not employ
any person in any manner so as to become sari ct to he Work :Camp n Laws of Ca11. All roofs shall be inspected prior 1 any roofing material being
fornia. (�j/, Installed. If a roof is installed without first obtaining an
Date.F-r— 9 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and WIII comply with all non point
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 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 of verin St0 Cl ss f or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in.
spection purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, AwcJ 7
judgments,costs and expenses which may in any way accrue against said City in consequence SI A 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY