R-0232 PERMIT R_ 0���
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
WITHIN 180 DAYS OF PERMIT ISSUANCETOR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDINGADDRESSBUILDING USE
-7
f �� '/N, a RESIDENTIAL COMMERCIAL OTHER
OWNER'S
( // HAZARDOUS ROOF
NAME Ian,, T. �h Qtr/ . � /N FIRE COVERING
- AREA CLASS
ADDRESS S C/ J J J UAI EXISTING ROOF COVERING
PHONE J
z — 9 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED � TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADDRESS
< CITY&ZIP EXISTING
PHONE BUILT-UP ROOF
LICENSE - ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
hereby elfirm the,1 an licensed untler provisions of Chapter 9(commem
eIng with Section 7000) of Division 3 of the Business and Professions Code, WOOD SHINGLES
nd my license is in full force and effect.
License Class Lic.Number.
Data Contractor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm t. ( . exempt1.5, from the Contractor'sosiLicense Law for PROPOSED
the fumy frIllbivyin6 reason. (Sec. permit, Business and Professions Code: Any city
re linty WhiCM1 requires a permit to construct, alter, improve, tlemolish,or
repair any structure,prior to Its issuance also requires the applicant for such BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
_h of the Contractor, License Law (Chapter 9 (commencing with SPttI.n7000) �? -
0f Division 3 of the Business and Professions Code)or that he is exempt there ASPHALT SH ING LES
fir m oand the basis for the alleged exemption. Any violation of Section
-�J 7031,5 by any,applicant for a permit subjects [M1e applicant to a civil penalty
of not more that five hundred dollars( 500).):WOOD SHAKES
❑ I,as owner of the property,or my employees with wages as their sole
com pensalion, will do the work,and the structure is not intended o offered
for safe (Sec. 7044, Business and Professions Code: The Contractors License WOOD SHINGLES
Law does opt apply to an owner of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that
such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building or improvement sold within one year of completion, the owner
builder will have the burden of proving that he did not build or Improve for
purposeoa sale.). PROVIDE I.C.B.O. REPORT NO.
❑ s owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Low does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
Who builds or improves thereon, and who contracts for such projects with a
contractors)licensed pursuant to the Contractor's License Law,
❑ I am exempt under Sec. ,B.B�P.C.for this
reason
- FASTENER
_own - Det /i
WORKERS'COMPENSATION DECLARATION
I hereby affirmthat have a certificate of consent to selo-msurs,or a ter TYPE
tificate of Workers' Comppnsalion Insurance,or a certified copy thereof(Sec.
3800, Lab.C.).
Policy No. Company
❑ Certified copy is hereby furnished. LENGTH Q�
O Certified Copy is filed with the city inspection division.
App1ican[ FEE SUMMARY
CERTIFICATE E EXEMPTION FROM WORKERS'
COMPENSATION S millet INSURANCEperm
(T1t'm suction need not he completed if the permit Is for one hundred dol- v v v
Isis(stoo)or lass.) VALUATION
<eI she thin in employ
performance of any
work for as which [M1Is permit
lied, r ell not employ ianyon Parson in any m er so as[o become zublect
to the Workers'Compensation laws of Californian
Dela Applicant ( tY a'(1
NOTICE TO APPLICANT: If,o after Workers'
this Certificate or Eons ofion, PERMIT FEE3�
you should become subject to IIIC comply
with
Compensation provisions of the
Labor dee you must forthwith comply with such provisions or this permit
shall be deemed revoked. DATE OF APPLICATION
1 certify that I have road thia application and state that the above informs -�
[ion is correct. I agree to comply with all city and county ordinances and
11-18 laws relating to building construction, and hereby authorise represen-
ta[ives of this city to entenupon the above mentioned property for inspection 66
purposes, I
(We) agree to save, indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against liabilities,judgments,costs and expenses which may in any way accrue
again}saitl City in c grantin0 of this
1�a � qe�� ,�� uv- /�./yds—
tun of A Ilca t/Contractor Date
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