00040055•
•
CJ
OFFICE,ICOPY
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBS
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228, PERMIT EXPIRES IF WORK IS NOT STARTED
- WITHIN 1W DAYS OF PERMIT ISSUANCE OR
' 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
,
RESIDENTIAL_ COMMERCIAL OTHER
OWNER'
- HAZARDOUS FIRE AREA
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Join
VES ❑ It yes - I understand that a Class A
NAME I' , `r N \ 1 rD rC1..A
root assembly is iequlred. -
NO ❑ Imbal LQB.O. N
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ADDRESSQ_. L4 Q5 T 1A �Qvi, AV`Q •
'' EXISTING ROOF COVERING
PHONE CA so 10NUMBER
OF EXISTING COVERINGS 06421
TO BE REMOVED TO BE RETAINED
CONTRACTOR'S [' 1^(
ADDRESS
Zto � CK S"L,
TYPE F ROOF VERING
CITY 8 ZIP `O JO-('+ ,'Q
EXISTING
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PHONE
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BUILT-UP ROOF ���❑
LICENSE�!3
NUMBER 3
ASPHALT SHINGLES
- O
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed Chapter
under provisions of 9 (commencing with Section
7000) Division
WOOD SHAKES ❑
of 3 of the Business and Professions Code, and my license is In full force and
atlas. r� /-�1
License Class `-' —look
WOOD SHINGLES ❑ VA Tf-k
Lic. Number
1 �
OTHER (SPECIFY) �5 IiI?i
Oats Contrator
c
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the fol ng reason.
PROPOSED
(Sea. 7031.5, Business and Professions Code: Any airy or county which requires a permit to
_
construct, alter, improve,demolish, or repair any structure, prior to its Issuance, also requires the
applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
BUILT-UP ROOF ❑
'
of the Contractors License Law (Chapter 9 (Commencing with Section 7000) of Division 3 of the
Business and Professions Coda) or that he is exempt therefrom and the basis for the alleged
ASPHALT SHINGLES ❑
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not Moro than five hundred dollars ($50D).):
\�I �I`
WOOD SHAKES
Ol, as owner of the property, or my employees with wages as their sole compensation, will do
the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Proles-
-
' sions Code: The Contractor's License Law does not apply to an owner of property who builds or
Improves thereon, and who does such work himself or through his own employees, provided that
,yVQQD SHINGLES ❑
such improvements are not intended or offered for sale. If, however, the building or Improvement
-
issoldwithinoneyearofcompletion, the owner -builder will have the burden of proving that he did
OTHER
not build or improve for purpose of sale.).
(SPECIFY) .❑ _
❑I, as owner of the property, am exclusive contracting with licensed contractors to construct
the project (See. 7044, Business and Professions Code: The Contractor's License Law does not
r /
'PROVIDE I.C.B.O. REPORT NO. E5
apply to an owner of property who builds or improves thereon, and who contracts for such projects
with a contractogs) licensed pursuant to the Contractor's License Law,
❑ I am exempt under Sec. ,B It P. C. for this reason
`
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
-
�1Qlkhave and will maintain a Certificate of Consent to self -Insure for Worker's Componsation,
e�4�owtletl for by Section 3700 the Labor Code, for
L
/
Building
of the performance of the work for which Nis
permit is Issued. -
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RllLeve and will maintain Worker's Compensation Insurance, as required by Section 3700 of
the abor Code, for the of the work for this is issued.
Seismic
performance which permit My Worker's
Compensatio��sgrepc� cXa1rrier and Policy number am: 3 _ 1 ^ q' 7 SZ
6
O
Total
PERMIT AUTHORIZATION
DATE
rd
Caer l 0 PolicyNo.
' CERTIFICATE OF EXEMPTION FROM WORKERS'
_
COMPENSATION INSURANCE N.C.i]
(This section need not be completed If the permit is for one hundred dollars ($100) or less.)
I certify that in the performance of the work for which this permit is issued, I Shall not employ
All roofs shall be inspected prior ny roofing material being
any person in any manner so as to become subject to the Workers' Compensation Law. of Cali.
fornia.
installed. If a roof is installed without first obtaining an
Date Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: if, alter making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will cont
PP ply with all non point
with such previsions 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 r00 gs be I Ss C. orb er.
hereby authorize representalives of this city to enter upon the above-mentioned property far in-
spection purposes.
(We) agree to Save, indemnity and keep harmless the City of Cupertino against liabilities,
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00
judgments, costs and expenses which may in any way accrue against Bald City in consequence
of the granting of this permit.
SIG UREOF APPLICA - DATE
PRE -INSPECTION:
PLYWOOD:
IN-PROGR
INSP. -DATE
'INSP. DATE
INSP. DATE
TEAR OFF INSPECTION:
BATTENS: -
FINAL:
INSP. DATE
INSP._r DATE
INSP. -DATE'—
DATENOTE:
NOTE:OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE,ICOPY