R-0125 - PERMIT O1 Z5
APPLICATION FOR CITY OF CUPERTINO NUMBER R
r
REROOF PERMIT INSPECTION DIVISION- PERMIT EXPIRATION PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
1-31 RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME �il CS/C• FIRE COVERING
AREA CLASS
ADDRESS /7"f�/ ��J/�.r1ir I�/ EXISTING ROOF COVERING li
PHONE 2 j "� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME s c ei t/C Nc TYPE OF ROOF COVERING
ADDRESS,
CITY& ZIP Lc•igL,�a •ljoy_� � EXISTING
PHONE 1 T2 -L7 v'Z BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER /fL WOOD SHAKES
L I CENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commeo- .,
WOOD SHINGLES
ring with Section 7000) of Division 3 of the Business and Professions CodeY
and my license is i full and effect. /
License Class Lic.Number OTHER (SPECIFY)
Data Cont racmr
OWNER BUILDER OECLARA
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the following re (Sec. 7031.5, Business and Professions Code: Any city
u city which requires a permit t0 a nztruet,alter, improve, demolish,or
repair any structure,prior to its issuance also requires the applleant for such BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
of ma Contractor's License Law (Chapter 9 (commencing with Section 7000)
A f Division 3 of the Business and Professions Code)or that he is exempt there. ASPHALT SH ING LES
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 bet more maf five hundred dollars 155001.): WOOD SHAKES
❑ I,as owner o1 the property,or my employees with wages as their sole
compensation,wn4l do me work,and the structure is not intended or offered WOOD SHINGLES
for sale (Sec. 704 , Business and Professions Code: The Contractor's License
Low does not apply foe of property who builds Or Improves thereon,
and who does such work himself or through his own employees,provided that
such improvements are not 'intended or offered for sale. If, however, the OTHER (SPECIFY)
building or mprovement 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 of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner Of the property,am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: TheContractors License Law does not apply to an owner of properly PROVIDE MFGR. INSTALLATION SPECS.
who be Ids Or improves thereon, and Who contracts for such projects with a
contractor(a)licensed pursuant to the Contractor's License Law. )
❑ I am exempt under Sec ,B.&P.C.for this - FASTENER p(
reason d
Owner Data
WORKERS'COMPENSATION DEC sent to ON `� It
.I hereby affirm that l nava i certificate of consent to copy Cher o TYPE 1 I
3 00, of Workers'Compensation Insurance,or certified copy thereof(Sec.
380q Lab.CJ. Imo-
Polity No. Cornu any �(d�{�,
FFTT��ererea copy hereby nrmsh d. LENGTH
�Cer[fi y is lad ith i [y inspection division.
Applicant r�ce'`�ill�cni c, FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol-
Tete(5100)or less.) VALUATION
I certify that in the performance of the Work for Which this permit is
issued, I shall 'Io t employ any person y m Z4,o bye/cpme
m.subject
to Wor the us o nApplicdLaws of C9Ljf= "J�.`" /�
is
Date Applicnt
FIC ICE TO/APPLICANT _•H,.after king m Certificate of Exemption, PERMIT FEE T�3- SU
you should become-P.Ii j no the Workers'Compensation provisions of the
Labor-Code;yyou must forthwith Comply with such provisions Or this permit -
shall bedeemedrevoked. DATE OF APPLICATION
I certify that I have rood this application and state that the above in forma-
tion is correof, I agtoe to comply with all city and county ordinances and
"tote laws relating to building construction, and hereby authorize represen
tativez of this city to enter upon the above mentioned property for inspection
purposes.
par PERMIT VALIDATION
(We) agree to save indemnify and keep harmless the Clty of Cu tine
against liabilities,judgments,costs and expenses which may in any way accrue
C 1
against z id C'i'ty, 9ro
jequence of the nting Of this parmi ' /
40
SiBnem re of Applicant/CSS n[ractor Dete
le Ji
REQUIREDPRE-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