99120061•
32(�:,
APPLICATION FOR
REROOF PERMIT
thfiAV EL
ADDRESS 1"ql STb k15S
CITY OF CUPERTINO
INSPECTION DIVISION
(408)777-3228
NAME A-4/bRE' EaKSiRON
ADDRESS �/ Hfk?-19ON A✓E
ADDRESCITY & S
O/Jl�np q rj y—p
PHONE c,,# PpE-i_L. Cl� elf qO 370'10
I hereby will that I am licensed under provision. of Chapter B fcommencing with Sechon
7000) d Division 3 of the Business and Professions Code, and my, Icer. Is In full force entl
effect.
License Clens/C JQ� Lk. Number
Dote /5>��/( commuter
OWNER BUILDER DECIARATION
I hereby affirm Net I am exempt from the Conlractofe License Law for the following reason.
(Sec: 7031.5. Business and Profeaslorns Cade: Any city or county which requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to Its Issuance, also requlrea the
applicant for such Permit to file a ogned statement that he is licensed pursuant to the prwlelorne
of the Contractor's License Lew (Chapter B (commencing with Section 7000) of DM.kn 3 of the
Business and Professions Code) or that he Is exempt therefrom and the heels for the alleged
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than Hve hundred dollars
I, as owner of the property, or my employees with wages as their sole canpensatlon, will do
the work, and the structure is rat Intended!
or offered for sale Sea. 7044, Business and Proles.
alone Code: The Contractors Ucense Law Coen not apply to an owner of property who Wlids or
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, howel the wilding or Improvement
i5 sold within one year of completion, the owner-buiker will here the burden of proving that he did
not bulk or m prore for purpose of sale.).
❑ I, as owner d the property, am exclushely contracting with licensed contractor to construct
Me project (Sec 7044, Businses and Profession. Code: The Contractor's License Lew does not
apply to an owner of property who builds or improves Marcos, erg who con rads fa noir projects
with a Owmacto(s) licensed pursuant to Ne Contractors Lkan er Lew.
❑ I em exempt under Sec: ,B & P. C. for NW reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby aHlrm under penalty of perjury, one of the following dectamtlon:
❑ I have and will maintain a Certificate of Consent to self -Insure for Workers Compensation,
as provuled for by Section 3700 of the Labor Code, for the performance of the work for which this
permit is Issued.
Mel have and MII maintain Worker's Compensation Insurance, as required by Section 3700 of
the bon Code, for the performance of the work for which Nis permit Is Issued. My Workers
Compensation Insurance carder and Policy number are. �s �y
Carrier S;Tf7e FUND Policy No% + 5063" / y
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CL]
(Tills section neetl rot be completed H the permit is for one hundred dollars (Sino) or lase.)
I certlty that In the performance of the work W which this permit Is issued, I shall not employ
any person in any manner as as to become eublect to me Workers' Compersatdn Laws of Cell.
forrea.
Date Applicant
NOT IThe
TO APPLICANT: If, alter maklrng this Cerrificete of Exemption, you should become
subject to e Workers' Compensation proylsion. of the Labor Code, you must forthwith comply
with such provisions or Nb Permit shall be deemed re:aked.
I col that I have read this application end stand that the above Informanloa is correct. I epee
to campy MN all city and county ordinances and state laws relllrg to bullding construction, and
hereby authorize representatives of This city to enter upon the above-mentloned property for in-
speclion purposes.
(We) agree to Saye, indemnity and keep harmkse the City of Cupertino against IiabilHles,
judgments, costs and expenses which may In any way accrue against send City In consequence
of the mendrg of this oermlt.
• PRE -INSPECTION:
INSP. DATE
TEAR OFF INSPECTION:
INSP
BATTENS:
PERMff
NUMBE
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
1B0 DAYS FROM LAST CALLED INSPECTION.
RESIDENTIAL (` COMMERCIAL OTHER
YES ❑ N yes - I undemlend that a Clans A
roof assernhty is required.
NO ❑ Initial I.C.B.O. N
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
IYPE OF ROOF COVERING
ASPHALT SHINGLES
WOOD SHAKES ,
WOOD SHINGLES
OTHER (SPECIFY)
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
JAPPLICATION DATE1 VALUATION I - PERMIT FEE I
Building
3� O d0 Seismic
Total a (0 • JV
PERMIT AUTHORIZATION DATE
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an
Inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
source regulations.
All roof coverings to be class or better.
49 k ls,/9�i%
SIGNATURE OF APPLICANT - DATE
INSP. - DATE
FINAL
INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION