R-0172 PERMIT R_ 0172
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN ISO DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESSBUILDING USE
10/ RESIDENTIA I COMMERCIAL OTHER
OWNER'S
�
(�,w//�. 1 HAZARDOUS ROOF
1..
NAME �/ Y�� N FIRE COVERING
//�/ AREA CLASS
ADDRESS
J��((/^ EXISTING ROOF COVERING
PHONE - NUMBER OF EXISTING COV RINGS
)
CONTRACTOR'S
NAME ///(�/j J� ��l/s TO BE REMOVED i TO BE RETAINED
TYPE F ROOF COVERING
CITY&ZIP Z/O �i�(////5 EXISTING
PHONE
�,� ZCp((� j BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER
WOOD SHAKES
A �
LICENSED CONTRACTORS DECLARTION
I hereby affirm that 1 am licensed under provisions of Chapter 9(commen-
ding with Section 7000) f Divi:ion 3 of the Business and Profso eS Code, WOOD SHINGLES
and my license is In II fpr a and
Deffect (l"7
y aansacless - Lic Number
GG OTHER (SPECIFY)
Date /.�-/ Contractor
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the following res (Sec. 7031.5, Business and Professions Code: Any city
u my whichrequires a permit 10 construct, alter, improve, dem OliSM1,or
rrepair any s+rucNra,prior to its issuance, a1e0 requires me applicant for such BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provision:
.rCly�. Of the Contractor's License Law (Chapter 9 (commencing With Section 7000)
of Division 3 of the Business and Professions Code)or that he Is exempt there ASPHALT SHINGLES
from
roth ntl ethe basis for-,he allegedmi exemption. Any violation of Section I�
fd any applicant for a permitubjectz the applicant f0 a civil penalty
of not more that five hundred dollars($500) .1: WOOD SHAKES
0 I,as owner of the property, or my employees with wages as their sale
tmperealion,will do the work, and the structure is not intended or offered
oor sale (Sec. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
Law does not apply to an Owner OI property who ti or improves thereon,
and who does such work himself Or through his own employees, however,that
such improvements are not intended o he Vs. for sale. ti botheyor, the OTHER (SPECIFY)
building or have movement is sold proving
to a yea,of completion, the owner.
builderos will have tM1¢ burden of OrovinB that M1a did not build or improvelor
Purpose sal s oiwno PROVIDE I.C.B.O. REPORT NO.
❑ I, construct
the property, a c.exclusively contracting a with licensed
cant rectors to c nstor's the project (Sec. t app Bly usiness peso and Professions
ode: ldsorihe prove'shereonense Law andwhscotfoauchpar of ojects with PROVIDEMFGR. INSTALLATIONSPECS.
wno budtls o improves thereon, end who contracts fore La projects whh a
contractors)am. licensed pursuant to the Contractor's License Law. TI
❑ lam exerl under sea. ,B.a P.c.for this FASTENER
reason
owner Data
WORKERS'COMPENSATION DECLARATION f /
I hereby affirm that I have a certificate of consent to sof insure,or a car. TYPE VUN
lifirete of Workers' Compensation Irui a c tifmd copy t e act(Sec.
role,Lab Compen 6
C tread cope is nerebv m.ni:hes LENGTH 0/
Ap CDllified copy iS vd with��si l peetlOn division.
�� � - 0
p CERTIFICATE OF EXEMPTION FROM WORKERS' FEE SUMMARY
COMPENSATION INSURANCE
be compI l
This section need not be completed if the permit is for one hundred deb
lars(9t0D)or less.) VALUATION
c
ro ¢rtdy that in the performance of the work for which this permit Is
d, all Shnot employ any person in'any manner so as to become subject
to Ne Workers'Compensation Laws of California. V
Date Applicant
NOTICE TO APPLICANT: If, outer making this Certificate of Exemption, PERMIT FEE a St
you should become sublact to the Workers' Compensation provisions of the
Labor Code, You must forthwith comply with such provisions or this permit DATE OF APPLICATION
Shelf be deemed revoked.
I certify that I have read this application and state that the above informer
cion is correct. I agree to comply with all city and county ordinances and • �+�
state laws relating to building construction, and hereby authorize repr¢sem
Atives 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
against liabilities, judgments,costs and expenses which may.in any way accrue
\ againn aai [y in cque ce of Ie granting of this permit.
«i ( Signature.of Appercant/C nVlidWr Data
REQUIREDPRE-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