R-4150 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERRIa 4150
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERM TISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRE�SSJ,� - BUILDING USE
212 1✓' RESIDENTIAL COMMERCIAL OTHER
• OWNER'S �\`
NAME k \ � HAZARDOUS ROOF
FIRE ( J COVERING
AREA n.[/ CLASS
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADDRESS
CITY&ZIP EXISTING
BUILT-UP ROOF
PHONE
LICENSE ASPHA GLES
NUMBER OD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(cdRlm.T
cin, With Section TOM) of Division 3 of the Business and Professions Code, W SHINGLES
and my license Is In full force and affect.
Lic•na Clea Lt..Number
Date Contractor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
hereby affirm That I am a.empt from the Contractor's License Law for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
or county which requires a permit to c nstruct, elbr, ins Drdv.d•molim,or
,.pair any structure.prior to its issuance,also requires the applicant for such BUILT-UP
permit to Ne a signed statement that he is licensee pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
Of Division 3 of me Business h and Proalleged
...m Dogiel v mea he is n of S dere SPHALT SHINGLES
from and the basis for the alleged exemption. Any ant to
dl Section
703ot o any applicant re a permit subjects the applicant[O•civil penalty
of not mon that live the pro dollars r my employees.1:
❑ I,e u of tate°.°parry,dr he reiwith wands as r air red
fon Selo
(Sic. will do tate work, and me ens Code:
is not intended Contractor's offered
for sola (sec Tppl Business end Profession Coda: TaterimpoverLicense WOOD SHINGLES
Lew doe not apply to an owner of through
who builds to improves thereon,
she who don such work not int or through M1 r own employees,provided that
such improvements are not intended or offered for om u, however, me OTHER (SPECIFY)
building or improvement av $ buris a°le within one year of completion, tate owner.
builder will have me burden of proving that M1a did not build or improvefor
D ° o1s1a.). 1 PROVIDE I.C.B.O. REPORT NO.
es owner of the property, am exclusively contracting with licensed
coactors to construct the project (Sac. 7099, Business and Profession$
e: TheContreclof'sLicense Low does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
builds or improves thereun,and who contracts for such project.with e
to traclor($)licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec. ,B.&P.C.for his ppLICATlON DATE VALUATION PERM( FEE
Owner Date .�
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I have a certificate of consent to sell insure,or a car
tific'se of Workers'Compensation Insurance,or s certified copy thereof(Sec. 0,9 19 Sei,- L
3800,Lob.C.I.
Policy No. Company c/'
BCertified copy is hereby furnished. Y set' Total
Certified copy IS filed with the city inspection division. (e VI`I Ly I
Applicant .I
CERTIFICATE OF EXEMPTION FROM WORKERS' N C ❑ PERMIT AUTHORIZATION DATE
COMPENB INSURANCE
(This section need not be completed if [M1e permit is for one nuneratl dol
bat($100)or Ins.l /
I Artily [hat m me performance of ma work for which this permit is C7/
issue
I he not employ any person in any manner SO ea to become subject
t0 the Workers'Compensation Laws of California,n
Data Applicant
NOTICE TO APPLICANT: 11, after making this certificate of Exemption,
you should become subject to the Workers' Compensation provisions of he
Code, you muss forthwith comply with such Provisions or this permit
shall deemed med revoked. All roofs shell be inspected prlortoany roofing material being
mall
I ceTfy that I n.ve read this application and Stan mat he above inform.. installed If a roof is installed withou irst obtaining an
"..I
en is correct 1 'gree to C.PIC Y wi[n all city and county ordinances end j0a eC �O I agree t em VB 11 ate , /rials fofin8 CtIOn.
nota laws Z'tina ro building c mOuceion, .nit hereby authorize represent. P 9 P
tntiva of this city to enter upon the above mentioned property for inspection - x
purposes. ^ e��
IWsI apse to sive, indemnify and keep harmless the City of Cupertinou
against liabilities,judgments,costs and expanses which may in any way accrue
against said City in consequence of the granting of this permit !SIGrNATURE OF APPLICANT- FDOE
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