R-0167PERMIT
APPLICATION FOR CITY OF CUPERTIN NUMBER R- 0167
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT PERMtT E%PINES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
'
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME
FIRE COVERING
AREA CLASS
_
EXISTING ROOF COVERING
ADDRESS
D
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR'S
TO BE REMOVED TO SE RETAINED
TYPE OF ROOF COVERING
NAME
ADDRESS, /
CITY•& ZIP L
EXISTING
BUILT-UP ROOF
PHON� —
ASPHALT SHINGLES
NUMBER ' V
�,, n
WOOD AKES 4= I ELI,tlC.•
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 heommem
ring whosection 7000) of Division 3 of the Business aPid.Profasfions Code,
WOOD SHINGLES
and myhennse is tells a and eue°c O/D
License toss Lie Number
OTHER (SPECIFY)
Do
Do,. cpntranpr
OWNER -BUILDER DECLARATION
I hemby ii that 1 am e.empt from the Contact is LoRel. Law for
PROPOSED
the following reason. (Sec. 7031 S, Business and Professions Code: Any city
Or co U Pity which requires a POrm it to construct, alter, improve, dem Olizh,Or
repair any structure, prior to its issuance, also requires the applicant for such
BUILT-UP ROOF
Permit to the a signed statement that he. s licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
vision 3 of the Business and Professions Code) Or that he is exempt thew
of Dis
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
of not more that five hundred dollars ($500).1:
ODD SHAKE
❑ I, as owner of the property, or my employees with wages as their sole
compensation wi I do the work, and the structure is not intended or offered
for sale (Sec. '044, Business and Professions Code: The Contractor's License
D SHINGLES
Law does not apply to-aer 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 D offered for sale. It, however, the
OTHER (SPECIFY)
building o Improvement Is sold within one year of completion, the,owner-
bullder will have the burden of proving that he did not build Or improve for
Purpose of sale:.
PROVIDE LC.B.O. REPORT N0.
❑ 1, es ow er of the Property, am exclusively contracting with licensed
t0 construct the project (Ser. 7044, Business and Professions
c"ntractor:
ode: The Contractor's License Law does not apply toanowner ofproperly
PROVIDE MFGR. INSTALLATION SPECS.
who builds Or improves thereon, and who Contracts for such projects with a
contractor(s) licensed pursuant t0 the Contractor's License Law.
❑ I am exempt vgde} Sac. ,B.&R.C. for this
FASTENER
A
Owve Dale
WOR KERS' COM P ENSATION DECLARATION
hereby affirm that have certificate of consent to self insure, ace.
TYPE
,file's of Workori Compen sati on Insur9nce, or a car tif ietl ap y m reo f ISec.
3800, Lab. CO.
Policy N0. ompenv
gcenu ad cop oby fu'I". f
LENGTH �-
Cec into co ilea w'th 1M1
FEE SUMMARY
Apt —1
CER IFIC OF EX M ,ION F WORKERS'
'
MPENSATION INS NCE
(Thissection head n01 be roto of led If the Permit is for an no n died dol -
'
lays ($1'01 or less.; -
VALUATION
I certify that in the performance of the work for which this permit is
Issued, 1 shall not employ any person in any manner so as to become subject
to Lha Workers' Compensation Laws of California.
—
Date App'feent
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
PERMIT FEE fs• SC%I•%7/C of
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such Provisions or 1M1iz permit
DATE OF APPLICATION
shall be doomed revoked.
I certify that I have read this application and state thai the above Informs
Pen is correct. I agree to comply with all city and county ordinances and .
slate laws .mating t I" c nstrutimn, and north, ammo.;:° represen
.
T.ves of this cI D ante Pon tha above mentioned property for inspection
PERMIT VALIDATION
purposes.
s the City of Cupertino
(We1 cer 10 Ind-&�hc'
against Iia iC ludgmen ts, sh may in any way accrue
ty in consaqua s Por it
f
Sip Lure o scant/C Pit for Dem
ReQUIREDnJO PRE -I CTION
IN-PROCESS,INSPECTION
FINAL INSPECTION
INSPECTIONSI.\N
INSPECTOR DATE
INSPECTOR DATE
INSPECTOR DATE
1
NCO• E: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED. FOR INSPECTION
INSPECTOR