R-0182 PERMIT R_ 018�?�
APPLICATION FOR CITY OF CUPERTINO NUMBER' GG
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
PERMIT EXPIRES IF WORK IS NOT STARTED
- f WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1 180 DAYS FROM LAST CALLED INSPECTION.
•s' BUILDING ADDRESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWN 'S
/7� HAZARDOUS ROOF
/7�l1f�
NAME l.. /\—SGL. FIRE COVERING
AREA CLASS
ADDRESS / -�����s�" f�L� EXISTING ROOF COVERING
PHONE — NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ' TO BE REMOVED PTO BE RETAINED
NAME G 4 TYPE OF ROOF COVERING
RESS
CITY&ZIP S'S'S {�a� 11-10di ' iy , EXISTING
PHONE BUILT-UP ROOF
S
LICENSE ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
hereby aflum that am licensed under provisions of Chapter 9(commem
pine with Section 70001 of Division 3 of the Business and Professions Code, WOOD SHINGLES
and mV license is is II f and effect.
License Clays•- Lit-Number-
Darn_7^'7" Contractor — ,� OTHER (SPECIFY)
OWNER-BUILOER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for PROPOSED.
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
Or c unty which requires a permit [O construct, alter, Improve;demolish,or
repair any structure, Prior to its 'issuance, also requires the applicant for such BUILT-UP ROOF
Permit to filo a signed statement that he IS licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
o1 Division 3 of the Business and Professions Code)or met he is..ompt there. ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section /, /
'-+•.�' of 31 not by any,applicant fora permit subjects the applicant to a civil penalty WOOD SHAKES d�_t�V , ./.KiC'
"1. of not mono that five hundred dollars r My e.7:
❑ 1, a owner Of me property, o he employees with wands as lM1air sole
fomole (Sic. will do the work, and the structure is not intended offered
r sato ' no 7044, Business and Professions Coda: The r improves
thereon, WOOD SHINGLES
Lawadd does not such to an Owner Of property who builds to i es, ovo5 Sher that
antl improvements
does such work not
self Or intended
r offered his own emalle. if,provitletl met
sum ng or improv are not old wed hr neya for sole. ti , thevoa owner OTHER (SPECIFY)
building il improvement t e bur Is sold within one year of o completion,or tot owner
builder will have the burden of proving that he did not build or Improve for
purposem5owne PROVIDE I.C.B.O. REPORT NO.
❑ I, r of me property, t ( exclusively contrasting with licensed
conlreclors to construct tM1¢ project (Sec. 7044, Business and Professions
Code: The Contractors License Law 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
contractor(s)licensed pursuant to the Contractor's License Law.
❑ I am ..ompt under Sac. ,B.&P.C.far hisreason FASTENER
Owner Data
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self-insure,or a ser TYPE S p,.� p
fifice to of Workers' Compensation Insurance,o certified copy thereof(Sec C
;if 12
380q Lab.C,). L 1r rU✓[ /J
Certified
erb R `f
Policy Company e 4 s/�
' 1ksorod rogv is hereby furnished. LENGTH
certuiod�uv'Br a w' me � iAepocn on division.
Apnbcant FEE SUMMARY
CERTIFICATE OF EXEMPTION ROM WORKERS'
COMPENSATION IN ANCE
(This section need not be completed If the permit is for one hundred dol.
lars(S 00)or Ites.) VALUATION
I certify that in the performance of the work for which this permit is
issued, 15hau nor employ any person in any manner so as to become subject
to the Workers'Compensation Laws of California.
Date Applicant ` / J'U
NOTICE TO APPLICANT: Ii, after making this Carti icatn of Exemption, PERMIT FEEid (I Selify IIL f ��
you shou Id become subject to the Workers' Compensation provisions of the
Labor Cade, you must forthwith comply with such provisions or this permit
shall be deemed revoked. DATE OF APPLICATION
I tartitV that I have read this application and state that the above laforyI
Hip
is correct. 1 agree to comply with all city and county ordinances and �t
state laws rOla[ing to building construction, and hereby authorize represem f,
tativers Of this city to enter upon the above-mentioned property for inspection b
purposes.
(Wm 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
agai [said City qua of[h granting 0f this permit.
.lW
Signature 91 AppII t/C t Ct.1 Data ,
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