R-0150 al
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 0150
REROOF PERMIT
INSPECTION DIVISION PERMIT eXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCEOR
180 DAYS FROM LAST CALLED INSPECTION.
., f BUILDING ADDRESS BUILDING USE
/0Z-T t- ��N� �n RESIDENTIAL—)CCOMMERCIAL OTHER
S
I OWNER'S •' HAZARDOUS ROOF
NAME !�'- �__I FIRE COVERING
I fr �/J r1 � - AREA CLASS
ADDRESS_/ 020 -Z EXISTING ROOF COVERING
PHONE - NUMBER OF EXISTING COVERINGS
CONTRA?
R'S
�` "rG�J l.,-o�"9�YI^^'�' TO BE REMOVED TO BE RETAINED
NAME
TYPE OF ROOF COVERING
ADDRESS,
CITY&ZIP /r/ 6 d+�,�,�f ,J1 5�,..c` � y EXISTING
/`18 �^sr7•z
PRONE 279 •—�/Yio BUILT-UP ROOF
LICENSE 7� ASPHALTSHINGLES
NUMBER 7 D.SH
LICENSED CONTRACTORS DECLARATION
I hereby affirm that jam licensed under provisions of Chapter 9(comment
rung with Sort.. 7000).of Division 3 of the Business and Professions Code, WOOD SHINGLES
and mylicense a in f I olree and even. �/��t'
license Class '� Lic.Number
Date — IC Can tmchar OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm.that I 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 ,o construct, alter, Improve, demolish,or
�'^• repair any structure,prior to Its issuance, also requires the applicant far such BUILT-UP ROOF
permit to file a signed s,atement toe,he is licensed pursuant to me provisions
. � of the Contractor's License Low (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions code)or that he is exempt mere_ ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
.�•r 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
Of not mem that five hundred dollars($500).): OOD SHAKE
Cl I, as owner of the property, or my employees with wages as mair'sOle
compensation, will do the work, andthe structure is not Imputed o offered
r sale (Sec 7044, Business and Professions Code: The contractor's License WOOD SHINGLES
Law does not apply to a n of property who builds Or improves thereon,
and who does such work hi ms
e Ifor through his own employees,provided that
such improvements are no, intended o offered for sale. If, however, the OTHER (SPECIFY)
building o improvement is sold within one year of completion, he owner
builder will have the burden of proving that he did n0, build or improve for
purpose of Sale,), PROVIDE I.C.B.O. REPORT NO.
❑ o
I, 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
contractor(s)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. ,B,a P.C.for this
anon FASTENER
Owtar Data
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to sell insure,or a cern TYPE / ( �✓a V'M � `JCnG o>
,ificate of Workers' Compensation Insurance,or a certified copy thereof(Sec. �-
3800, Lab.C,). fir
Policy No. Company
gCanI led copy is hereby turnlsnad. LENGTH
eenired cony is film with me city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' FEE SUMMARY
COMPENSATION INSURANCE
(This sec,ion need net be completed if he permit is for one hundred doL �� V
lar.(810.)or less.) VALUATION
I certify that in the performance of the work for which ,his p rmit is
issued, shell not employ any person in r as to become subject
to the Workers'Co "u-sans, Laws of C a f manner so
Date Applicant
Non APPLICANT: If, afterD this car, icata f Exemption, PERMIT FEE �J S E-/J7y, C—
:
You should become subject to the Wor:erz' Compensation provisions of the
Labor Code,you must forthwith comply with such provisions Or this permit
shall be deemed revoked. y[; DATE OF APPLICATION
I certify that I have read this application and state that the above informs' u
--tion is cOnecL I agree to comply with all city and county ordinances and a
state laws relating to building construction, and hereby authorize represent t'
ta,ives of this city to enter upon the above mentioned property for inspection
purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against liabil itis$$$,ludgmanta,cost and expanses which mem in any way accrue �/
• � against seitl Cy(v inFonzeauanc me 9ranting of this Perr11=1_ `� Vp•'`/ ti/ 7(�� }////
Signature a ApPIQi/'c_en_t/Co_nt etor Data
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE_ INSPECTOR CI DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF.SHALL BE PROVIDE FOR INSPECTION
INSPECTOR COPY