R-0209 [NUMBER
RMIT R_ OZOJ
APPLICATION FOR CITY OF CUPERTINO
REROOF PERMIT INSPECTION,DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
a. SI 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
Q3LlQ Lct 6 RESIDENTIAL COMMERCIAL OTHER
OWNER'SROOF
M '{—`�
NAME / ` ` L' 1ys FIREAR DOUS COVERING
AREA CLASS
ADDRESS �!� �[\�. EXISTING ROOF COVERING
PHONE — NUMBER OF EXISTING COVERINGS '
CONTRAC S
TO BE REMOVED TO BE RETAINED
NAMET TYPE OF ROOF COVERING
ADDRESS, \_
CITY&ZIP r� V.J-1r EXISTING
PHONE N—t Z1 �C- � BUILT-UP ROOF
NUMBER( � QjQ — '� ASPHALT SHINGLES
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affront that 1 am licensed under provisions of Chapter 9(commen-
cing with Section 7000)of Division 3 of the Business and Professions Code, WOOD SHINGLES
end my license ia,in f a and effect.
License Class L=u�f rce LIC.Number �• _�
Data W Comra.To, r Aeess OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for PROPOSED
the following reason, (Sec. 7031.5, Business and Professions Code: Any city
or County which requires a permit to c nstruct, alter, improve, dem°Iish,Or
repair any structure,prior to its issuance.also requires the applicant for such BUILT-UP ROOF
permit to file a signed statement that M1e is licensed pursuant t0 me provisions
of the Contractors License Law (Chapter 9 (commencing with Section 7000)
Li Division 3 of the Business and Pr.ld ions Code)or that he Is exempt there ASPHALT SHINGLES
y from and iM1e basis for the alleged exemption. Any violation of Section
,• of 31 hot by athat five
hu fora permit subjects me applicant Ina civil penalty WOOD SHAKES
of not more that five the property,
siphons r my employees
'• ❑ I,as owner of me property, or he employees wim wages as mein sole
for sale (Sec. 7044,
win do me work, and me structure is net intended 's License WOOD SHINGLES
for sale Isec, apply Business and Professions Code: The Contractor's License
law does not apply to an owner of property who builds to improves provided
that
and who does enM1 work not
int or through o rgM1 M1is own employe vs, however,
mat
such ng or Improv a not old wild Ln °Hared for Rale. D, however,owner OTHER (SPECIFY)
building i Improvement t e bur sold within one year of completion,or p Owner
purpose
will neve the burden of proving that he did not build or morose for
punpesv of sale.),wnPROVIDE I.C.B.O. REPORT NO.
❑ I, as Owner OI 1M1e property, exclusively Businesscontractingan with licensed
contractors Contractor's construct me project Les tapp Business an r Professions
code: ThaorimprovesLicensely PROVIDEMFGR. INSTALLATIONSPECS.
who builds o licensed
ps thereon, and who contracts fore La projects with a
convect a- licensed pursuant to the Contractor's License Law.
❑ lam exempt under sac. ,B.aP.c.for Ibis FASTENER
j
Owner Data
1 WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self insure,or a cer. TYPE \ Q \J
tiflcate°I Workers' Compensation Insurance,or acertified copy thereof(Sec.
3800, Lab.C.).
Policy No. Company
cerdned copy is hereby furnished. , LENGTH
❑ Cle pled copy Iz filed with the city inspection division. T
Appgcant FEE SUMMARY
! CERTIFICATE OF EXEMPTION FROM WORKERS' y' I
COMPENSATION INSURANCE
(This section need not be Completed if the permit is for one hundred doh
1 lars(stow or less.) VALUATION
I certify that in the performance of the work for which this permit Is
lied, I hall Ot employ any person y yyy so as 1e become subject —•
to the N rk Is ompensathin Laws of IC a It
Date Q Applicant
NOTICE TO APPLICANT: If, after making his Certificate of Exemption, Sts Ar1-`7
vno should become subject to the Workers' Compensation provisions of the PERMIT FEE T'f'
Labor Cade, you must forthwith comply with such provisions or this permit
shall be deemed revoked, DATE OF APPLICATION
I certify that I have read thif application and state that the above informs `
It Is correct. I agree to comply with all city and county ordinane as and
state laws relating to building construction, and hereby authorize represon- / �s
tatives Of this city to enter upon the above mentioned property for inspection
purposes,
PERMIT VALIDATION
(Wel) s m
agree to indemnity and keep harmless e City of Cupertino
against liabilities,judgments,costs and expanses which may in any way accrue _
against said City in consequence of the granting of this permit.
Signature of Applicant/Contractor is Dere
f
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
::F
INSPECTIONS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY