R-0239PERMIT R_ 0239
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
�� J/
\\�- �� �f/T'v' ��/
7
7
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME -
FIRE COVERING
AREA CLASS
EXISTING ROOF COVERING
ADDRESS — �
/
NUMBER OF EXISTING COVERINGS
PHONE 7
CONTRACTOR/'S
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
NAME
ADDRESS,
CITY & ZIPS/EXISTING
BUILT-UP ROOF
PHONE/��eg
,�O��i
ASPHALT SHINGLES
LICENSE_
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisionsm
of Chapter 9 (coment
Section loom of Dmiai on 3 of the Business and Professions Code,
WOOD SHINGLES
aiwith
nd mV license is in ful �`re effect.
��
License Che Lic. Number
OTHER (SPECIFY)
Date — — contra<mr
OWN- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for
PROPOSED
the following reason. (Sec..7031.5, Business and Professions Code: Any city
or county which requires a permit to construct, alter, improve, demolish,Or
repair any structure, prior to its issuance also rewires the applicant for such
BUILT-UP ROOF
permit 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)
of Division 3 of the Business and Professions Code) or that he is exempt there
ASPHALT SHINGLES
frons and the basis for the alleged exemption. Any violation of Section
7031.5 by any, applicant for a permit subjects the applicant to a civil penalty
of not more that five hundred dollars ($500).):
WOOD SHAKES X
❑ I, as Owner Of the property, Or my employees with wages as their sole
wmpenaa ion, will do the work, and the structure is not Intended or offered
for sale (Sec. 7044, Business and Professions Code: The Contractor's License
WOOD SHINGLES
Law does not apply to a of property who builds or improves thereon,
and who does such work himself or through his own employees, provided that
lithimprovemwts are not intended or offered for sale. If, however, the
OTHER (SPECIFY)
build l ng Or improvement 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 Ofsam.).
PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the property, am exclusively contracting with licensed
to construct the project (Sec, 7044, Business and Professions
contractors
ode: ThaContractor's l-icenseLaw does not apply toanowner ofproperty
PROVIDE MFGR. INSTALLATION SPECS.
who bush s or improves thereon, and who contracts for such project, with a
onlrector(s) licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec. ,B.&P.C. for this
reason
FASTENER
W errs Data
WORKERS'COMPENSATION DECLARATION
hereby affirm that have certificate of consent ora
TYPE
ie coposura,
[if state of Workrz' Co11 n3 Insurance, Or a certified copy there f (Sec.
3800, Lab. C,) �70i7 iJ /,,[ /
Policy No. Company S/iRlj�P
p cemnod copy is hereby famished.
LENGTH J'
.p certiRed copy is riled with he city inspacnon rhvislon.
FEE SUMMARY
A ant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
(This section need not be comploted if the permit Is for one hundred dol
A
Tars ($100) or less.)
;VALUATION
I certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner s0 as to become subject
to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, atter making this Certificate of Exemption,
PERMIT FEE
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
DATE OF APPLICATION
shall be deemed revoked.
I certify that I have read this application and state that the above informs
tion is correct. I agree to comply with all city and county ordinances and
state se
laws relating to building construction, and hereby authorize repren.
a/
tenses of this city to enter upon the above mentioned property for inspection
/ PERMIT VALIDATION
purposes.
(Wel agree to save, indemnify and keep harmless the City of Cupertino
against liabilities, judgments. cost of expenses which may In any way accrue
again .said CITYqr �,/P�ewers m ammg of mss permit.
- n
S erestuuie--�of��papppppl{{{cant/Con acts Date
PRE -INSPECTION -
IN -PROCESS INSPECTION
FINAL INSPECTION
REQUIRED
INSPECTIONS
hINSPECTOR DATE
INSPECTOR DATE
INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR