R-0148 PERMIT R_ 0148
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
w. WITHI N 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
- - BUILDING ADDRESS' BUILDING USE
IS(e� �f"'rG'pl Lam. Ct.�Psr l:.moo
—'{ RESIDENTIAL !!!i COMMERCIAL `• OTHER
OWNER'S
HAZARDOUS ROOF
'NAME �� FIRE \ COVERING
--,, AREA CLASS
ADDRESS E. EXISTING ROOF COVERING
PHONE Z�S7 — Z'ZI 9 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S TO BE-REMOVED TO BE RETAINED
NAME C�`I Pam-. � ' a`CS TYPE OF ROOF COVERING
ADDRES
CITY&ZSF 41121 - �w.wr gl.�eC • 1C....o-. EXISTING
PHONE li — 33"71 BUILT-UP ROOF
LICENSE '�j79 — '-��'� ASPHALT SHINGLES
NUMBERWOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed unite,provisions of Chapter 9(common•
mg with Section 7000) of Division 3 of the Business and Professions Coda, WOOD SHINGLES
and my license is in fV I"i and effect.
License Class ` —/ Lic Number — �v�
Data tE !!!r Co. ra°Ior < �_ .',.S OTHER (SPECIFY) gags 25
OWNER BUILDER DECLARATION
I hereby affirm Ill., I am exempt tram the Contraero:s License Law for PROPOSED
[M1e following reason. (Sec. 7031.5, Business and Professions Code: Any city
or county which requires a permit to construct, alter, improves, dem°lizh,or
repair any structure, prior to its issuance also ,, quite, the apdooant for span BUILT-UP ROOF
Palen to fila a signed statement that he is licensed pursuant to the provisions
Of the Contractor's License Law (Chapter 9 (commencing with Section 71
of Division 3 of the Business and Professions Code)or that he is exempt that.'. ASPHALT SHINGLES
from and the basis for me allegedexemption. Any violation of Section
7031.5 by any,applicant for a permit subjectsthe spplic Ont to a cpenalty
civil penal
of not more that nvo hundred dollars($500).1: WOOD SHAKES
❑ I,asowns of the property, or my employees with wages as their sole -
cempensati°n,will do the work, and the structure is not intended p offered
to,sem (Seo. 7044, Business and Professions code: The Contractors License WOOD SHINGLES
Law does not apply 10 an West of properly Who builds or improves thereon,
and who does such work himself or through his Own employees,provided that s�_
such improvements are not intended or offered for sale. If, M1OWOVer, the OTHER (SPECIFY) I�Cfa- T:le ' Ac
building or improvement is z°Id within one year of c mpleti°n, the owner
builder will have the burden of proving that he did not build or improve for
purpose 1, a :own, PROVIDE I.C.B.O. REPORT NO.
1, as st me property, aexclusively04, contracting with licensed
ccontractors to construct the project (Bac. ]044, Business and Professions
oda: The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who bullas or improves thereon, and who contracts for such projects with a
contractor(s)licensed pursuant to the Contractor's License Law.
p I am exempt under Sea ,B.&P.C,for this FASTENER
C
ason Owns, Date
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have certificate of consent to self insure,o TYPE
tificeta of W°rIIsy i� ,,or -sayjerylnsurance,or a certified copy thereof fSec.
380Q Lab.c.1.kC_r IS) Ompanyny /1 vol
Policy Ger Company K� 1
�❑ car mica cony is hereby lentis d. LENGTH
Certl1etllgO�dy' tiled w�l Ei[y it spedntlivislOn.
Applic Ont R I ` FEE SUMMARY
CERTIFICATE E EXEMPTION FROM WORKERS'
COMPENSATION be co TION INSU a NCE
perm
(This section need not be completed it the permit is for one hu ntlretl itch
jars($100)or less.) VALUATION �Ze✓GJ
1 :artily that in [M1e performance of me work for Which this POrmit
ped, shall not employ any person in any m er s°as to become subject
to m°Workers'Compensation Laws of Californian
Dale Applicant �7 t/ _ - /
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, PERMIT FEE / T -- `sc/J/i Is b
you 6hould become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
shell be deemed revoked. DATE OF APPLICATION
I certify that I have read this application and state that the above informs
[Ion is correct. 1 agree to comply with all city and county Ordinances and
state laws relating to building construction, and hereby authorize represent
tatives of this city to enter upon the above mentioned property for Inspection
purposes.
IWe) agree to save, indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against liabilities, judgments,cons and expenses which may in any way accrue,
_ against said city in consequence of the granting Of this permit.
Signature of Applicant/Contractor Data
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY