R-0217 J
PERMIT . _ O��
APPLICATION FOR CITY OF CUPERTINO NUMBER R
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
.. WITHIN 180 DAYS OF PERMIT-ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
1-1, RESIDENTIAL COMMERCIAL OTHER
OW ER'S i
HAZARDOUS ROOF
NAME ` . \ '— n•P� tir ee FIRE COVERING
i
AREA CLASS
ADORE [y'ZL_ ',_rA ri�1`,��G�C�� • (��' EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING
COVERINGS
CONTRACTOR'S . TO BE REMOVED ✓ TO BE RETAINED
NAME �r� -� y. �,1� � �� TYPE OF ROOF COVERING
'- ADDRESS
CITY&ZI, ,( EXISTING
. .. P _�� �C Qw \ \� �c�
lam.
PHONE —ICJ � Cnycp1 "' eIl6 BUILT-UP ROOF� I
LICENSEASPHALT SHINGLES
NUMBER Liawcia, WOOD SHAKES -
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provisions-Of Chapter 9(commen
eung With Suction 7000) of Division 3 of the Business and Professions Code, WOOD SHINGLES
nd mylicense is ful orco and effect. 4 j
License Class Lic.Number I6 OTHER (SPECIFY)
Oate 2. s- L Contractor i
OWNER BUILDER DECLARATION
I INreby affirm that I am exemptldon, he Contractor', License Law for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
or county which requires a permit to con...qc,, alter, improve,demolish,or
repair any stcture, prior to its issuance also requires the applicant for such BUILT-UP ROOF
permlt to firule.signed statement that he is licensed pursuant to the provisions
01 the Contractor's'License Law (Chapter 9 (commencing with Section7000)
of Division 3 of the Business and Professions Code)or that he Is exempt there ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
I 7031.5 by any Spplicant for a permit subjects the applicant to a civil penalty
,.. of not more that five hundred dollars($500).): WOOD SHAKES
❑ I,as owner of the property, or my employees with wages as their sole
compensation,wig do the work, and the structure is not intended or offeree WOOD SHINGLES
for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of property who builds or improves thereon, j
and who does such work himself or through his own employees,provided that s
such improvements are not intended or offered for sale. If, however, the OTHER(SPECIFY) 7
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for /
purpose of sale.). PROVIDE LC.B.O. REPORT NO.
❑ I, as owner of the property, a exclusively contracting with licensed /
-contractors to construct the project (Sec. 7044, Business and Professions "
Code: The'C.m,act°r's License LAW does nor apply 1.ad own.,of property PROVIDE MFGR. INSTALLATION SPECS. J
wM10 builds or improves [hereon, and who contracts for such projects Wim a
ontractor(s)licensed pursuant to the Contractor's License Law. /
❑ I am axemp[ under sea ,B.a P.c.ter this FASTENER /
reason Date
Own., WORKERS'COMPENSATION DECLARATION it l
cate
hereby affirm [hat I have a certificate of corseet to selfinsure,or a oar. TYPE 02— S '/tr C V
tifiof Workers' Compensation Insurance,or a certified copy thereof(Sec.
3800,Lou.C,L s—
Policy No. Companyp CJn w t-� .�
oCertified copy is hereby fu mishod. LENGTH
Cartine,,d� py is filed wit .IOLG1jy m co5�i tion division.
^P°'i`°n�� s� c q FEE SUMMARY -.-
CERTIFICATE E EXEMPTION FROM WORKERS'
COMPENSATION S millet INSURANCE
(This($ 0 section need not be completed if the permit is for one M1untlretl tloh !!//
lora(sell,)or less.) - VALUATION
certify that in the performance of the work for which this permit is
uetl, I shell not employ any person in any manner-so_es to become subject
D Ne Worker'Compensation Laws of California,
'
Date AAT: [Int // ('''
NOTICE TO APPLICANT: N, hear making o is Certificate of Exemption, PERMIT FEE �"'/"fL .J C/fM Al
you should become subject to the Worker' Compensation Provisions a the
hallCCode,
deemedlnook¢d'or[hWitfi comply with such provisions or this perms[ DATE OF APPLICATION
s certify that l have read this application and slate the,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 au thorizo represen-
to ti ves of this city to enter upon the above mentioned property for inspection tI
purpaaes. - - r y PERMIT VALIDATION
(We) agree to save, indemnifyand keep harmless the Cit of Cupertino
against IiobiliYp ts,costs and expanses which me,in any Way dctrue
r against$said Ci 1 the granting of IhisParm)L
! mor or A-pplicant/CoNclor Dotal
./ REQUIRED PRE-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