R-0157 PERMIT R_ 01 ��
APPLICATION FOR CITY OF CUPERTINO i�` NUMBER
INSPECTION DIVISION P ERMIT EXPIRATION
REROOF PERMIT vTHIN 180 DAYS OFPEMIT ISSUANCE
.! 180 DAYS FROM _,ST CALLED INSPECTION. `
BUILDING ADDRESS BUI LDING USE
' ' "� ✓s��+ RESIDENTIAL COMMERCIAL \OTH�E/ERR,�/"
OWNER'S
Mr HAZARDOUS ROOF
NAME /,1 L� r-f, FIRE COVERING
f, AREA CLASS
ADDRESSJiYy GL/hs r+' EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACT S
J TOBE REMOVED TO BE RETAINED
NAME �C) TYPE OF ROOF COVERING lid
ADDRESS
•
CITV &ZIP (,,J/ EXISTING
�,}�/p
PHONE Z 1 r I J BUILT-UP ROOF
LICENSE lJU'1V-UH ASPHALT SHINGLES
NUMBER WOODSHAKES >l
- LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(rammed
/ ung with Section 7000) of Division 3 of the Business and Professions Code, WOOD SHINGLES
�1
no my license is 11 tome ane affgm.
License Cl asz,a �_ Lic.Number
Data �T��-T - contactor OTHER (SPECIFY)
OWNERBUILDER DEC LA RATI
I hereby affirm that I em exempt from the Contractor's License Law for PROPOSED
the following reason. (Sac. 7031.5, Business and Professions Code: Any city
linty which requires a permit to construct, alter, improve, demollsh,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
i 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 and the basis for the alleged exemption. Any violation of Section
�5_ 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
� .» of not more that five hundred dollars($5010).): WOOD SHAKES
❑ I,as Owner of [M1e property,or
my employees with wages as their Sole
mpensati on,will do the work, and the structure is not intended or offered WOOD SHINGLES
for sale (Sec. 7044, B.Sinss and Professions Cod.:Cod.: The Contractor's License
Low does not apply to a r of property who builds or Improves heard,
and who does such work himselfor through his own employees,provided that
uch Improvements a not intended r offered for sale. u, however, he OTHER (SPECIFY)
rmpr
building r ovem nc
t sold within one year of completion, he r
builder will have the burden of proving that he did not build or improvener for
Purpose of Sale.). PROVIDE I.C.B.O. REPORT NO.
C] I, as owner of the property, am exclusively contracting with licensed
contrar tors to construct the project (Sec 7044, Business and Professions
ode: ThaContracfor'sLicense Law does not apply toanowner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds Or improves thereon, and who contracts for such projects with a
cont actor(s)licensed pursuant to[M1e Contractor's License Law.
❑ I am exempt under Sec. - ,B.&P.C.far hisreasFASTENER
Owner Date
WORKERS'COMPENSATION DECLARATION
hereby affirm that I erne i certificate of consent to copy
o a retie TYPE. G/�f/ ,'�•,�,,I(_�'I•C. L✓
3800, of Workers'Compensation Insurance,or a certified copy thereof(Sec,
3800•Lab.C•1. .mss f
Policy No. Company
yfurni
g Candled copy is hed withrthe cit n LENGTH
certified copy I tiled with me city inspection division.
Applicant FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE d/
(ThiS section n ed not be completed if the permit is for one hundred dol- O q
lars($100)or less.) VALUATION
I certify that in the performance of the work for which this permit i
uCi, I shall not employ any person i pp armor zp a to•became subject
to the kers'Co - nsation Laws at Ca(f ,:d !
Date '���P$} APpllca^t
IN IC rTTAA PLICANT: I+, after n g this c r Irlcata o+ Exemption, PER FEE D `S 'fes' e•
you should become subject to he War a s' Compensation Provisions of the
Labor Code,you must forthwith comply with such provisions or his permit
Shall be deemed r.y.kad. DATE OF APPLICATION
I certify that I have read this application and State that the above informs!
Ran is correct. I agree to comply with all city and county ordinances and
state laws r elating to building construction, and hereby authorize represen-
tatives at this city to enter upon the above mentioned property for inspection
purposes.
(We) agree toe indemnify and keep harmless he City of Cupertino PERMIT VALIDATION
age,nst iablli z,judgments,costs and expenses which may in any way accrue
a9.I nst said �i coni a o+the granting of this peZmit.
Signature f 1Aiziplicant/C&IIIIIr Date
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
Y-Z
&r
INSPECTIONS
INSPECTOR DATE INSPECT DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY