R 3274 (2) PERMIT
APPLICATION FOR CITY OFCUPERTINO NUMBER R- 327
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
(408) 252-4505 EXT. 228 WITHIN 180 DAYSOF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING
�ADORES�S BUILDING USE
2 (Q l/l VIS. l yWl�� RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZI
. �
FIRE COVERING COVVERING
'NAME AREA CLASS
• ADDRESL1/.4(�a OM- 6
M- Cain' EXISTING ROOF CO ERIN
pG
P' PHONE l 1 , V7' NUMBER OF EXISTING COVERINGS
CONTRACTOR'S TOBEREMOVED TO BE RETAINED
,
NAMECpk
TYPE OF ROOF COVERING
yy�
ADDRESSIps //j �//I�I,6IC EXISTING
PHONE c1(A_ I'-I 'CU BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER WOOD SHAKES I
LICENSED CONTRACTORS DECLARATION
I m
hereby affirm that I am licensed antler provision,of Chapter 9(comam
cin, with Section 7000) of Division 0 of the Bu,ino a r ten Code, ' WOOD SHINGLES
and my Ilcensa is in and elect.
License qes— LIC.Number
OTHER (SPECIFY)
Den nt
V Coractor
OWN9R BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Lew for PROPOSED
the following reason. (Sec. 7031.5, Business and Profession,Code: Any city
Or County which requires a permit to construct, alter, Improve, demollth,or
repair env structure, prior n its issuance,also requires the applicant for such BUILT-UP ROOF
permit tO ills a signed statement that he it licensed pursuant to the provisloni
of the Contractor', License Lew (Chapter 9 (commencing with Section 7000) 'I
• of Division Sof the Busmen and alleged
Profession,tion. or.net he tion of
theca' ASPHALT SHINGLES,P A
berm grid the appl for the el loped exemption. Any violation of Section
710not 15
31 more
five
lic ant lore permit subjects 1M1a applicenl to a civil peneltY
Ct not mor.that Roe hpndr.d dolled(ESam.L WOOD SHAKES
❑ I,ai Owner of the property,or my employee,with wends es r offered
ifrole 89T
fomp.n aeon,will do me work, and me nrvCode i. not (mantled '.License WOOD SHINGLES y� �1 1996
for ala(Sec. )044, to neo and Professions property
Code: The Camra ove s License
Lew don not apply to an owner of property who builds to improves provided
that
and improvements
doe, ant work himself or edro r o his own employee,,providetl aM1at
such impwvamann are not intended or offered for ales If, however, me OTHER (SPECIFY)
�urcntuulf
building or improvement i, sold within one veer of completion, the owner.
builder will have the burden of proving Inst he&I not build or improve for
Purpose Pf..l..1. PROVIDE I.C.B.O. REPORT NO.
❑ I.
as owner of the property, em exclusively contracting with licensed
contractors to construct the project (Sac. 7044, Business and Professions
Code: The Contractor, Lic.m. Law do.,not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who build. Or improve,thereon, and who contracts for such projects with e
contractor(s)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sac.reason ,B.&P.C.for this
Own., Dar. APPLICATION DATE VALUATION PERMIT FEE
WORKERS'COMPENSATION DECLARATION
1 hereby Workers
that 1 neve a certificate t consent to sell insure,ora can
0800`L 1 WCrkeri o p /;on
Policy No, "ConlPenv v. ^tel " / E C
8 Certiliatl copy n hereby furnished.
Certified copy is filed with the city inspection division. V
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT VALIDATION DATE
COMPENSATION INSURANCE
' (Thi,section need not be completed if the permit is for one hundred dol
lar.(E100)or lest.)
1 certify that in the performance of the work for which this permit i, �O
sued, I tba11 noemploy any person in any manner so et become subject
to the Workerit n
n Compensation Laws of California,
e Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Examptlon,
you should become subject to the Workers'Compensation provisions Of the
Labor Code,you must forthwith comply with such Provisions or this permit All types of roof shall be inspected prior to any roof being installed,To
.wan be deemed.evok.a, receive a final I em aware there will be three approved inspections:
Certify cher I have read this comply
with all
icy a d that ah.ordi a cos a a Pre, 10 /0 cess,and final. If roof is applied without first obtaining an
tion i. Curren. I agree ro comply wild en chy end county 0rdinencm end P 9
„at. laws relating to building construction, and hereby .uth,,i. ..pr...m inspection, I agree I will remove all new material for inspection.
tatives of this City to anter upon the above mentioned property for Impaction
Purpose'.
(We) agree to nve, indemnity and keep harmless the CITY of Cupertino
against liabilities,judgment,,cost.and..p.m...Which may In any way accrue
. again,,said City in consequence of the gnnsing Of this perms.
SI NATURE APPLICANT DATE
REQUIRED PRE-INSPECTION IN-PROCESC)SPECTIOV FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY