R-0204 PERMIT R- 0204
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
' BUILDING ADDRESS BUILDING USE
Q RESIDENTIAL COMMERCIAL OTHER
WNER'S
(%!/r��� REAR HAZARDOUS
ROOF
NAME F COVERING
C AREA CLASS
ADDRESS GL/�'Y�I EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR - -
TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADDRESS, • T
CITY&ZIP EXISTING
PHONE 241:53V 7 BUILT-UP ROOF
LICENSE -�. ASPHALT SHINGLES
NUMBER WOOD SHAKES
�c LICENSED CONTRACTORS DECLARATION -
�xx hereby at into that I am I soused under provisions of Chapter 9(common-
in9 wi[b See[ipn 7000) of Division 3 of the Bus m :and Prof es:ion:Cpde, WOOD SHINGLES
and my licen; o f'I for etlect.
License Class s Lic.Number,
oat _ cnmra<tpr OTHER (SPECIFY)
ER BUILDER DECLAR TIO
I hereby affirm the, I am exempt from the Contractors License Law for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Coda: Any ckV
or county which requires a permit to construct, alter, improve, dem Olish,or
repany structure, prior to its issuance, also requires the applicant forsu<M1 BUILT-UP ROOF
permit t0 fire a signed statement mn 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 the,he is exempt there
from and the basis for the alleged exemption. Any violation of Section ASPHALT SHINGLES
•;' 7031.5 by any applicant for a permit subjects the applicant t0 a civil penalty
of not mere that five hundred dollars(S500).): WOOD SHAKES
o
�, ❑ I, as w r Of the property,o my employees with wages as their sole
Pont pensat'mn,w �
in do the work, and the structure is not intended or offered WOOD SHINGLES
for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply t0 an Owner OI properly who builds Or improves[hereon,
sort who does such work himself or through his own employees.Provided that
such improvements are not intended oroffered for sale. It- however, the OTHER (SPECIFY)
building o improvement is sold within one year of Completion, the Owner
foul our will have he burden Of proving that he did not build or improve for
purpose oa:own, - PROVIDE I.C.B.O. REPORT NO.
❑ I, st me property, t ( exclusively Businss contractingPr licensed
cCorrectors to construct the project (Sec. t app Business ners antl Professions
oda: The Contractor's License
on,and doeswho contracts
for
:such pr of property
a PROVIDE MFGR. INSTALLATION SPECS.
who beads I improves thereon,t, and who actoraca for Soso projects with a
coMrec son licensed n er and to the Contractor's License Law.
ea❑n am exempt under sec ,Bra P.e.for his FASTENER
Owner Oatn
WORKERS'COMPENSATION DECLARATION
hereby eairm that have a n Insurance.
of r a sen[ ie sell
copy Cher o TYPE
tifica,e qt workorz' Compensation Inwran<e,ora certified copy merest Isec.
3800,Lab.CJ.
Policy No. Company / }
Cerin n aheebv carni a. LENGTH , '
Certif o filltl M1 t ty iim
/ photon `` n'A
L'EPTIFICATEE�MPTION FROM WO Rs• FEES Y
COMPENSATION I
be completed
INSURANCE
,This section need not be completed if the permit is for one hundred not
lays(8100)or last.) VALUATION
1 certify mat in the performance of the work for which this permit is
issued, shell not employ any person in any manner so as to become subject
to mo Workers'Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, PERMIT FE r
you should bocome subject to the Workers' Compensation provisions of the
Labor Code, you mus[forthwith comply with such provisions or this permit al
:hall be deemed revoked. Dfff TE OF APPILJ:CAIIDN
I certify that I have reed this application and stns that the ordinances
informs / //� "C
tion is correct. agree to comply with all city and county orize P r antl
state laws relating to building construction, and hereby au morize represem
tatives of this city to enter upon the above-mentioned property for inspection
purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
aBainit liabilities,judgme ts,cost ntl expert s M1icM1 may in any way accrue a7yy
B said ty c g ce he gran rm t. / '(/n0
.I r re of A •a V J
REQUIREDPRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
J:�
INSPECTIONS INSPECTOR DATE h INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED.ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY