R-0169 PERMIT Q
APPLICATION FOR1_1CITY-OF CUPERTINO NUMBER R— 0169
INSPECTION DIVISION PERMIT EXP,RATION
REROOF PERMIT
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
.. . 180 DAYS FROM LAST CALLED INSPECTION.
i BUILDING ADDRESS /�'' BUILDING USE
�S D-e r Ae D!^i //+ue li 'Z✓�_I✓t.0 RESIDENTIAL COMMERCIAL OTHER
OWNER'S
ROOF
NAME GCCV�/ ('� !v!rf C�S FIREAR HAZARDOUS COVERING
�J ! - j� /^ AREA CLASS
ADDRESS /`/ �5 be Foe A- try C. 4,ye✓�irei EXISTING ROOF COVERING
PHONE Z S 3 `��'� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED X
NAME TYPE OF ROOF COVERING
ADDRESS,
CITY&ZIP EXISTING
i
BUILT-UP ROOF
PHONE
LICENSE ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION X
her°byaffirm 00 of i visiotl 3 of
OtdP Chapter rOl9Ceemmde, WOOD SHINGLES
Ing with Secli on )000) of Division 3 of me Business and Professions Code, ^
anti my license is in full force and effect.
License Class LIc,Number
Data Contractor OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm that I a exempt from the Contractors License Lew for PROPOSED
the following reason (Sec. perms, 8u sinew and Professions Cede: Any city
or county tructura, Pries a permit to corrolmel,also re altar, improve, aemoll uch
repair any strucm r4, prior to ns iz:Fanta.also reauirps me applicant fpr such BUILT-UP ROOF 11I
p°rmh to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
- ` 01 Oivision 3 of the Business and Professions Code)or that he is exempt there ASPHALT SHINGLES
/!y from and the half s for ma alleged examptinn. Any violation pf Sector,
7031.5 by any,applicant ter a permitubjects the applicant to a civil penalty
of not more mat five hundred dollars(4500).): WOOD SHAKES J
❑ I,as owner of the property,or my employees with wages as their sole
mpensilon, will 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 a owner Of property who builds p improves thereon,
and who does such work himself or through his own employees,provided that
such improvemes are t intended or offered for sale. 11, however, the OTHER (SPECIFY)
build ng or improvement
ro
provement is sold within one year of Completion, the owner
builder will have the burden of proving that he did not build or improve for
purpose 91 PROVIDE LC.B.O. REPORT NO:
❑ I, as owner of the property, a xclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: ThaContractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
Who be ildt or mproves thereon, and who contracts for such projects with a
contractor ls)lic anted pursuant to the Contractor's License Law. -
❑ 1 am exempt under Sec. ,B.&P.C.for this FASTENER
reason
Owner Date ('
WORKERS'COMP SATION DECLARATION l J
lhemny affirm that i have a e°nireate of consent to self-insure,or cur TYPE
tifica In of W0rkeri Compensation Insurance,or a certified copy thereof(Sec.
3800,Lab.C.). •
Policy No. Company
❑ Certified copy is hereby furnished. LENGTH
❑ Certified Copy Is filed with the city inspection division.
Applicant f FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE I
(This section need not be completed If the permit is for one hundred dol-
lars($100)or less.) VALUATION zl c�
I fainly that in the performance of the work for which this permit is
uad, 1 shall not employ any person in any manner s0 as to become subject
10 me Workers'Compensation Laws of California.
Oate Applicant r
• NOTICE TO APPLICANT: If, after making this Certificate of Exemption, PERMIT FEE 3 d .�c�SH•e - �y
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions Or this permit/
shall be deemed revoked. - DATE OF APPLICATION
I petrify that I have road this application and state that the above informa
tion is correct i agree to comply with alt city and county ordinances and //��•��
state laws relating to building construction, and hereby authorize I.Irmiem
tatives Of this City t0 enter upon the above mentioned property for inspection
purposes.
(We),agrea to s indemnify and keep harmless the city of Cupertino PERMIT VALIDATION
against liabilities,judgments,costs and grant expenses which may in any way accrue
inst s 'd City In sequence oft a granting of this permit
tax
a gneture of Applicant/ ontractor Date /
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
---. INSPECTIONS INSPECTOR DATE INSPECTOR DATE_ INSPECTOR GATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY