99110182 1018
PER
APPLICATION FOR CITY OF CUPERTINO NUMBSRL
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
r RESIDENTIAL �/�c COMMERCIAL OTHER
OWNERS r HAZARDOUS FIRE AREA
[„- YES ❑ II as s I assembly
i req that a Class A
NAME 'e✓ 100 M 3 roof assembly is required.
� NO ❑ Imbal LC.B.O.If
ADDRESS
✓eWD S EXISTING ROOF COVERING
PHONE Q (? NUMBER OF EXISTING COVERINGS
CONTRA R'S n- L
TO BE REMOVED X TO BE RETAINED
NAME
ADDRESS / .�� I/. T -'1 � TYPE OF ROOF COVERING
CITY&ZIP
�S Lt1 S77— q_5��°Z EXISTING
PHONE 1_ T���l 97'1'- 7717 BUILT-UP ROOFLICENSE
NUMBER ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em 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 lull force and
affect. WOOD SHINGLES
License Class C" US,Numbed�+,,����� O
Date �t - 3/-ao Contractors / OTHER(SPECIFY) ^
OWNER-BUILDER DECLARATION PROPOSED V
I hereby affirm that I am exempt Imm the Contractor's 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 ram and the basis for the alleged ASPHALT SHINGL .x
exemption.Any violation of Section 7031.5 by any applicantantfor a permit subjects the applicant to U
a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES ❑
❑I,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 antl Profits. NOV (/f,.(J
Bions Code:The Contractor's License Lew tloes not apply to en owner of property who builds or WOOD SHINGLE Y Ly 999
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(SPECIF )B ❑
not build or improve for purpose of sale.). Y
❑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.REPO.
apply to an owner of property who builds or improves thereon,and who contracts for such projects
with a contractorls)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 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: q
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, I (-Y�) Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this !��
permit is issued. Seismic
I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the tabor Code,for the performance of the work for which this permit is issued.My Worker's —/ d J Total
Compensation Insurance carrier en Policy number are: �y7 (/�
Carrier �'/ -t -n All- Policy No.W����k3!l PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p
(This section need not be completed if the per is for one bund d rs($100)or less.) 2 �9
certify that in the performance of the work for which this permit issue shall not employ
any person in any manner so as to becomes 'act to the Workers' mpens tion Lawa of CTIi All roofs Shall be Inspected prior to any rooting material being
forms. installed. If a roof is installed without first obtaining an
Data (-L —99 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 understand will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply PPcanunersP y
with such provisions or this permit shall be deemed revoked. a fegD tlDns.
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 antl stets laws relating to building construction,antl All rO fCOV 'ngs to ass fbe er.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. I(-�L(--/�
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, 16
judgments,costs and expenses which may in any way accrue against said Cit In consequence IG 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY