99120017 9902 / PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBE
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (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
O L L It RESIDENTIAL COMMERCIAL OTHER
OWNER'S A HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME JF,C✓ UIJ OO iD roof assembly is required.
NO ❑ Initial I.C.B.O.#
ADDRESS I'1'1Z-b C,L LLW-11. -51I EXISTING ROOF COVERING
PHONE -79
NUMBER OF EXISTING COVERINGS 7—
CONTRACTOR
CONTRACTORC,.L
���=�\l1/ Ked�'1t1`lG.. TO BE REMOVED / TO BE RETAINED
NAME
ADDRESS ,[ TYPE OF ROOF COVERING
CITY&ZIP u
11. 'I EXISTING
PHONE -Cg_zfA)97! —1-7-77/ BUILT-UP ROOF
CENSE
NUMBER ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 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.
1.1� '?iiR '7 ! WOOD SHINGLES 10
lam/
License Class ii' G_ �Lic.Number W rr r `E 6�Z `�/
Date a Contract., SitC.1.�R�`. 1 IR�' _ OTHER(SPECIFY)
OWNER-the Conn DECL License
PROPOSED
hereby affirm that am exempt from the Contractor's License Law for the following reason. D ZJ
(Sec.construct,
al,Business and Professions Code: Any city or county which requires a permit to
construct,alter,improve,t demolish,a signed
or repair any structure,prior t.its issuance,also requires the BUILT-UP ROOF f
applicant for such permit 10 file a signal statement that he is licensor pursuant to the provisions DEC
of she Contractor's License Law)or that
9(commencing with Section thee)of for the 3 0l the ggg
• Business and Professionslotiof Code)or that ha is exempt ant for a and the basis for the alleged ASPHALT SHING S
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 hummed dollars(h wag): WOOD SHAKES ❑
❑I,as owner of the property,or to employees with wages a.their sole compensation,will do 13
the work,and the structure is not intended or offered for solo(Sec.]044,Business and Profes- B
signs Code:TheContractor's License Law does not apply to an owner of property who builds or WOOD SHINGLE Q
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 OTHER(SPECIFY) Elnot build 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.C.B.O.REPORT NO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under See. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: G c
I have and will maintain a Certificate of Consent to self insure for Worker's Compensation, I Z- 2- I �/ S�J Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit Is issued. $e15R11C
❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 01 27 Q I S 16 V, 7
the Labor Code,for the performance of the work for which this permit is issued.My Workers
Compensation Insurance carrier and Policy number are: L1 �y{ .,,I� Total
W U� V
Carrier RL�+.asw-t FROMNo. 7 PERMIT AUTHORIZATION DATE
CERTIFICATE EN EXEMPTION FROM WORKERS' /
COMPENSATION INSURANCE N 0)o C `TQC f 2
(This section need not be completed it the permit is lar one rt.lettere($100)or less.)
I certify that in the performance of the war k for which this it is fee um,I shall not employ
any person in any manner so as to become subject to the ars'Compensation Law.of call- All roofs shall be inspected prior to any loofing material being
arnia. 9 installed. If a roof is installed without first obtaining an
Date Z ` Applicant inspec ion,I agree to remove all new materials for inspection.
NOTICE T or ICANT. If,after making this Certificate of a tion,you s t I become A lica FT understa an will Comply with all non point
subject to th Workers'or Compensation provisions d the Labor Co you must forthwith comply P P Y P
with such provisions or this permit shall be deemed revoked. O Ica
regulations.
1 certify that I have read this application and state that the above information is correct. agree
to comply with all city and county ordinances and state laws relating to building construction,and All to f Cov Ings I be ss" r better.
hereby aphorize representatives of this city t.enter upon the above-mentioned property for in-
speWe)agree tos. 1�r /Q
(We)agree to save,indemnify and keep harmless the City ai Cupertino against Iiabilitias, r
ofjudgments,gran costs entl expenses which may in any way accrue against said City in consequence ATURE 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