99100057 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK ISNOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDINGGL1 ADDRESS
7� , LA_)t" RESIDENTIAL COMMERCIAL OTHER
OWNER' HAZARDOUS FIRE AREA
1\ YES ❑ If yes-I understand that a Class A
NAME G1-•Ci&1-1 �"r�1 C! roof assembly is required.
NO E] Initial 1.13,13.0.If
ADDRESS 22rrf.,f _ EXISTING ROOF COVERING
PHONE
AJCv _ 2-_7
/ Z NUMBER OF EXISTING COVERINGS Z•
i
CONTRACT R'S
_ TO BE REMOVED TO BE RETAINED
NAME O
r ADDRESS o,- // •/ p_�,C,� , l n c� TYPE OF ROOF COVERING
CITY&zip_�c.c/\ ' J�--•-Q' O �`�"7(�•�Y EXISTING
PHONE`// p?>7 � — 7f q 7 BUILT-UP ROOF ❑
LICENSE
NUMBER tb p 4/gi ASPHALT SHINGLES -❑
LICENSED CONTRACTORS DECLARATION -7 /O
hereby ithat am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES `
]000)of Division 3 of the Business and Professions Code,and my license is in full force and
effect.
I ' WOOD SHINGLES
License Class Lic.Number `T
/l
Data Contractor OTHER(SPECIFY) /
OWNER-BUILDER RAT PROPOSED
I hereby affirm that am exempt from the e: Any
city License Law for the following reason.
(Sec.]0315,Business and Professions Code: Any city or county which requires a permit to _
construct,ntforter,su improve,demto file signed sty any menstructure,that he Is licenor tosedts pursuanuance,t
also requires the BUILT-UP ROOF L
of the
applicant for such permit to fila a signed statement nci g with
Section
pursuant to the provisions
of the
Contractor's License Law(Chapter 8(commencing with Section]000)of Division 3 le ed
Business and Professions Code)or that he is exempt applicant
and the basis for the alleged ASPHALT SHINGL &
exemption.civilpelty oviolation tMo of Secthan
fie hundred
d any s($5 ant for a permit subjects the applicant to OCTq ^xs^
a civil penalty of not moro than five hundred dollars with
wag.): WOOD SHAKES C 1 999
❑I,as owner of the property,or to employees with wages as N.7 sole compensation,will s.
the work,and the structure is not intended or s not for sato(Sec.]044,Business and builds
o-
Isions mprovsth:The Contractor's License Law d apply to an his owof n rty
whowrovidethat WOOD SHINGLE ❑
Improves
thereon,and who tloen such work himself or through his own employees,provided that By-
is
y
such Improvements are not intended or offered for sale. ill however,the en of pr or improvement _
nsold tbuild or
prove for purpose
stheowner-builderwill havethe burden of provingthat hedid OTHER(SPECIFY
not build or improve for purpose of sale.).
❑I,as owner of the properly,am exclusively contracting with licensed contractors to Construct c �
the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.N C-1L 7s�
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractous)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
C]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:
r ❑I have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this Id// /�C OU
p It is issued. ��i Seismic
have antl will maintain Worker's Compensation Insurance,as required by Section 3]00 of
th Labor Coda for No performance of the work for which this permit is Issued.My Worker's
mpensatio ns nca arrier and Policy number are: Total
Carrier ,ara R_ Poficy No.1446 Vd3"?4? PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.j2 =�
(This section need not be completed if the permit is for one hundred dollars($100)or less.) �in 't-,7,_D li 6����/ y
1 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 became subject to the orkersI company Iron Laws of call. All roofs shall be inspected prior to any roofing material being
fOfnia. � a installed. If a roof is installed without first obtaining an
Date 0 / Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter making this Cerliticp a of Exemption,you should become Applicant understands and will I with all point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply comply Y wanon 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 roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
seethe)purposes.
(We)agree to save,indemnity and keep harmless the City ai Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence SIGNATURE O APPLICA T 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