R 7595 � l (oo So SZ� OOJ50/ �K
PERMIT R-
APPLICATION7595
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3'2'28 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS 10-71
� sot
KFC RESIDENTIAL COMMERCIAL OTHER
OWNER'S LL �p HAZARDOUS FIRE AREA
� VES ❑ pool assembly is requirednd that. Clew A
NO ❑ Initial I.C.B.O.N
ADDRESS EXISTING ROOF COVERING
PHONE &G SD 3 -1 Sa NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
I I 1 - �2,�` y TO BE REMOVED TO BE RETAINED
NAME l f�—
ADDRESS �7? � �,� N �� Walk TYPE OF ROOF COVERING
iTYEXISTING
PHONE `C BUILT-UP ROOF
LICENSE /
NUMBER --- ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby eHirm that I 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. T
7 "7/ WOOD SHINGLES ID
License Class �` � Lic.Numbert'P'� ` � C l
Date ^L1—OC::f` Contractor—C.+—L I�-�I OTHER(SPECIFY) ❑
OWNER BUILDER DECLARATION II PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Coda: Any city or county which requires a permit to
construct,alter,improve,demolish.or repair any structure,promo its issuance.alsorequlres 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 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 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 and Profes-
sions Code:The Contractor's License Law does not apply to an owner of properly who builds or WOOD SHINGLES ❑
improves thereon,and who does such work himself or through his own employees,provided that I
such Impmin one ts year
not intended at owner-Wilder
for sale. ill have the the building or improvement OTHER(SPECIFY)'Pt�h�l4tS
is sold within one year of completion,the owner-builder will have the burden of proving that he did
not build or improve for purpose of sale.). J
❑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 Lew 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 contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECIARATION
I hereby affirm under penalty of perjury one of the following declaration: G
1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, S L2— S' `� — Building
as provided for by Section 3700 of the Labor Coda,for the performance of the work for which this J
permit is issued. $eISn11C
have antl will maintain Worker's Compensation Insurance,as required by Section 3700 of
th La r Code,for the performance of the work for which this permit is issued.My Worker's TotalSv�+
C mpensati n nsuran opcarnor Policy bar are:
Carrier— `^i Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be Completed if the permit is for one hundred dollars($100)or less.) Q� N�i�ar ' .•,.
I certify that in the performance of the work for which this permit is issued.1 shall not employ
any person in any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior Mny roofing material being
tennis. installed. If a roof is installed without first obtaining an
Data 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 understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith Comply PP P Y 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 stale laws relating to building Construction,and AI Of COverin be lass"Ci"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
spection purposes. iZ�Q
(We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs and expenses which may in any way accrue against said City in consequence SI ATURE APPLICA T DATE
of the granting of this permit.
ft.
PLYWOOD: IN-PROGR S:
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