R-0133 X, '
PERMITR_
01
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT
INSPECTION DIVISION PERMIT EXPIRATION
tI PERMIT EXPIRES T WORK IS NOT STARTED
f WITHI N 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
\7!� BUILDING ADDRESS BUILDING USE
! 9 L U ioelz Ayep RESIDENTIAL_? COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME /./�IyIS fd SSO�. /�/a 2�Y ///AA eliI FIRE COVERING
AREA CLASS
ADDRESS/ '�' O�,Qpi2t4 SUi%O1 CU,QPtL�y EXISTING ROOF COVERING
i
PHONE
(� NUMBER OF EXISTING COVERINGS
3 � .J
CONTRACTOR'S -
..// // II TO BE REMOVED� TO BE RETAINED
NAMETIM 114,,.4 9N 6OD y��'yTYPE OF ROOF COVERING
CADDRESS
ITY&ZIP �� NEW n�tell (� d-"1 ?"'0;0 EXISTING �
PHONE O.3 D� BUILT-UP ROOF
LICENSE .ASPHALT SHINGLES /
NUMBER ef 3 3 S WOOD SHAKES /hid
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(common.
ing with section 7000) of Division 3 of the Business and Profession Code, WOOD SHINGLES
and my licenses in I onto antl effect � l20J
License Class Lia Number J
Data Contractor no OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
hereby affirm that I .m exempt from the Contractors License Law for PROPOSED .
the efollowing reason. (Sec. 7031.5, Business and Professions Code: Any city
rcounty which requires a permit to construct, alter, improve, demolish,or
epany structure, prior to its issuance also requires the applicant for such BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9 (comencing with Section 7000)
A f Divim
sion 3 of he Business and Professions Code)or that he is exempt mere ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
J1017031.5 by any,applicant for a permit subjects the applicant to a civil penalty /
of not more that five hundred dollars 135001.): WOOD SHAKES
❑ I,as owner of the property, or my employees with wages as heir..In
compensation,will do he work, andthe structure is not Intended or offered
for sale (Sec 7044, Business and Professions Code:'The Contractor's License WOOD SHINGLES
woeLaw do., not apply to an owner of property who builds or improves thereon, i
and who does such work himself or through his own employees,provided that
qch Immovements a not intended o offered for sale. If, however, the OTHER (SPECIFY)
building o improvement r
nt is sold within one year of ceintioplen, the owner
builder will have.the burden of proving that he did not build or improve for
purposeof safe.).; ' PROVIDE I.C.B.O. REPORT NO.
Cl as a of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
ode: TheContrastor'sLlcenseLawdoesnotapply10anownerofPropertyPROVIDE MFGR. INSTALLATION SPECS.
wh O,bu'Tels O improves thereon,and who contracts for such projects with a
erms�adtor(s)licensed pursuant to he Convector's License Law.
❑ I am exempt under Sec. ,B.&P.C.for this FASTENER
ows
nor DateWORKERS'COMPENSATION DECLARATION
I hereby affirm het I have a certificate of consent to self-insure,o TYPES714,01 P G
tilie.te of Workers' Compensation Insurance,or a certified copy thereof(Sec
3800, Lab.C.). a i." _ /
Policy ab Company /,;/
Certified copy Is homey furnished. LENGTH
Certified copy is filed with the city inspection division.
Applicant FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE I
(This section need not be completed if the permit is for one hundred dol. 9
rs($100)or less.) VALUATION 00
a I certify that in he perfonQEnca of he work for which this permit is
itauCQ shall Ot employ any person in ani, manner GOmaiubject (�,
to tho W r s' onset ion Lawz California. ^�
Date NTP If, n NJ'sV
No
E r APPLICANT: If,�a r maklp his Certificate of Exemption, PERMIT FEE /
- you should become subject to t Workeri ompenzation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
shell bedeamed revoked. DATE OF APPLICATION
I certify that I have read this application and state that the above informa
tion is correct. I agree to comply with all city and county ordinances and
R.R. laws relating to building construction, and hereby authorize represent
[olives Of this city t0 enter upon the above mentioned property for inspection
purposes. y , PERMIT VALIDATION
(We) agree t0 Save, indemnify end keno harmless the City p1 Cupertino
against liabilities, judgments,costs and expenses which may in any way accrue
- age' st sold City in a nseq Cnej�E"o/f�the gcoming of his permit. ,
�`�, IgneNr f Applicant/Contractor Data
REQUIRED PRE.INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS1 I INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY