R-3159 PERM T
APPLICATION FOR CITY OF CUPERTINO NUMB(R R 3159
REROOF PERMIT INSPECTION DIVISION - PERMIT EXPIRATION
(408) 252-4505 EXT. 228 WIRMIT EXPIRES IF WORK ED
THIN 180 DAYS OF P RMIT IS NOT
ETOR
' 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING(/}ADDDDDR�ESSS� BUILDING USE
�) V'�T l/� RESIDENTIA COMMERCIAL OTHER
OWNER' r,' "'• `v `n \flA I v'
HAZARDOUS ROOF
NAME FIRE p COVERING
AREA CLASS
ADDRESS Il EXISTING ROOF COVERING
PHONE 2 OR NUMBER OF EXISTING COVERINGS
CONTRA TOR'S '
OC1.._..^(� TO BE REMOVED TO BE RETAINED
NAME ii, TYPE OF ROOF COVERING
ADORES!
CITY&ZIP EXISTING
i
PHONE ��`7 _E BUILT-UP ROOF
LICENSE ,�y� ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 noepy aifi rid that I em licensed under provisions of Chapter 9(commem
ting with section 7000) o1 Oivi.ion 3 of In. Bu. e.a�IOd Professions code, WOOD SHINGLES
and my license is Jf(full and e".c\. )sf"J bO
Liana Cly ` Lic.Numbe LLIJJJCCi OTHER (SPECIFY)
Data Contractor
ER BUILDER DIECLAFthisiffili
I hereby affirm aliat I am exempt from the Contractor. Licama Lew far PROPOSED
the following reason. (Sac. 7031.5, Business and Profession Cotla: Any city - w`�
recounty which requires a Permit to construct,alter, improve, demol4h,or \
pair any structure, prior to In issuance, also requires the applicant for such BUILT-UP ROOF J
Permit to fila a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Lew (Chapter 9 (commencing with Section 7000)
• of Diving 3 of the Business Th end alleged
exemption.
xam tion. or that he is exempt Section
ASPHALT SHINGLES
from Wo the baais for the and
Pro a amp t ion. Any vibe is ex o1 Section
7031.5 by any.applicant for a Permit subjects the applicant t0 a civil penalty
of not more that five hundred dollars($5DD).r: WOOD SHAKESA
ClI,as owner of the Property,ormy employees with wages as their sole a A
compensation,will do the work, and The structure is not intended or offered
for.ale (Sec. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
Law does not apply t0 an Owner of Property who builds Or improves thereon, gp 2 p 7
and -no does JU
such work himself or Through his own employees,provided that �aNMVg '9Vq
such improvements are not intended or offered for sale. If, however, me OTHER (SPECIFY) Vs/
building or improvement is sold within one year of completion, the Owner
builder will have The burden of proving that he did not build or Improve for C(1y ah
purpose o�seowne PROVIDE I.C.B.O. REPORT N&LIf l flYu
[r I, st the property, a exclusively Business an with licensed
contractors to construct the project (Sac. 7064, Business and Proleuions
Code: Tn0Contractor'. License Law does not sooty toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thersun, and who contracts for such projects with a
convectors)licensed pursuant to the Contractors License Law.
C3 1 em exempt under Sec. ,B.&P.C.for this
reason APPLICATION DATE VALUATION P I F
Owner Date s
WORKERS'COM P ENSAcals DECLARATION N
I hereby affirm Net I have a art surate of consent le self in aura,or ter
fill
Ot WOrkeri Comp�se� nsu rents, III led copy tnereor ec.
3800, Lsb��'1y� Iy�/,1'I/�� SEI IC
Policy Nope
•��Certl�l9�cbp6 is hareb,fu r eil.
CertiHetl iled with Itsit,in =tion division.
Applicant _
CE RTI A c E OR KE RS' PERMIT VALIDATION DATE
COMPENSA , INSURANCE
(This section need not be completed if the permit Is for one hundred dols
ler.(5100)or less.)
00
certify that in the performance of Ne work for which in permit is
issued, Ishall not employ any person in any manner s0 as to become subject
to the Wo.keri Compensation Laws of California.
Deb Applicant
7jo
NOTICE TO APPLICANT: 11, alter making this Certificate of Exemption,
you should become subject to the Workers' Compensation Droviti On. of the
Labor Code, you must forthwith comply with such provisions or Ni. permit All types of roof shall be inspected prior to any roof being installed.To
.nal certify
deemed revoked.have
receive a final I am aware there will be three approved inspections:
I ca cafe Nat I gave rand Comply
ly with a .sit stand that the ordinances i ces nd Pre, in res ress, and final. If roof is applied without first obtaining an
tion .correct. I orae to ole with a city d county amerce. e P 9 PP 9
.tate few. relating o building construction, dna hereby authorize s p inspection inspection, I agree I will remove all new material for inspection.
quip. .. this city to anter upon the above mentioned property for impaction
pur(We)
(We)liabilities.agree save, In cos s and keep harmless torr City of Cupertino
against id IYi judgments,nsseecots and expenses f his may in any way accrue
again.[.eid City m consequence Of\M1a granting of Ni.permit. L
• SIGNATURE OF APP ICAN DAT
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION I FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
[NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY