R-0213 1
PERMIT R_ OZ1
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
x PERMT EXPIRES IF WORK IS NOT STARTED
6, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
h 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
RESIDENTIAL x COMMERCIAL OTHER-
OWNER'S
THEROWN R'S
HAZARDOUS ROOF
NAME �A w. .lixf FIRE COVERING
AREA CLASS
ADDRESS 61 L EXISTING ROOF COVERING
PHONE 1— 06
NUMBER OF EXISTING COVERINGS
fy
CONTRACTOR'S %nn / I
''//�'� TO BE REMOVED. -- TO BE RETAINED I
NAME r la hv-e ✓ IyLiJthG TYPE OF ROOF COVERING
ADDRESS, /G
CITY&ZIP S e '1 lha✓ QUt EXISTING
PHONE �qL-1 �l—{ l I BUILT-UP ROOF
8'
LICENSEASPHALT SHINGLES !I
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commem WOOD SHINGLES X
ting with Section 7000) of Division 3 of the Business and Professions Code,
and my license i u ful once and effect. 34b36L1
License Class - Lic.Number
Data 8_ — Contractor. yy� t e i OTHER (SPECIFY)
OWNER 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 CodAny city
Or county which requires a permit to construct, alter, improve, demo isll,or ,
repair env struomre, prior m its issuance,also require: the applicant for surch BUILT-UP ROOF
Perm h to file a signed statement thathe is licensed pursuanYm the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
f' of Division 3 of the Business and Professions Code)or that he is a himpt mercy ASPHALT SHINGLES
from 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 Q ee
`'•' of not more met uve hundred dollars 15500).1: } WOOD SHAKES M PGl1 U+�
❑ I,as owner of me property, or my employees with wages as their sale
compensation,will do the work, and the structure is not intended or offered WOOD SHINGLES
for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not 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 a not 'intended o offered for sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner.
buil dor will have'theburden of proving that he did not build or improve lor
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec 7044, Business and Professions
Code: The Contractor's 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
contractorls)licensed pursuant to the Contractor's License Law.
❑ 1 an, exempt under Sec. ,B.&P.C.for this FASTENER
rea
on
.Owsner Det.
WORKERS'COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self-insure,or a ter.
hficato of workers' Compensation Insurance,or a certified copy t ereof(Sec, TYPE �a 16dr �nTD I c 1
3800, Lab.C.). LL l Cy /
Policy No ALV- Company �'�- _ `l li L"",
p Certified copy is hereby furnisne� LENGTH 11
D Cerlif led c s filed with tM1e city inspection division.
Apph an, y....._._. vs', fes_ FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred deb
cars(8100)or less.) VALUATION 3 yO d
I certify that in the performance of ,he work for which this permit Is
issued, I shall not employ any person any m er s0 as t0 become subject _
to the We
Compensat ion Laws of Californian "
Date Applicant .Sv
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption, PERMIT FEE �� S�/SM/C �S`y
you should become subject to the Workers' Compensation provisions of the
Labor Code,you must forthwith comply with such provisions or this permit
shall be deemed revoked. - y. DATE OF APPLICATIONA
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 laws relating to building construction, and hereby authorize represem
tatives of this city to enter upon the above mentioned property for inspection v
purposes. v PERMIT VALIDATION
(Al agree to save, indemnify and keep Harmless ma city of Cupertino
against liabilities,judgments,costs and expenses which may in any way accrue
.gaind City in consequence of the granting of this par
se
Signature of Applicant/Convector D.ed �1 —✓ s.v s`---�L/
REQUIRED PRE-INSPECTION INPROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE:" OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY