R-0142 EN
RMIT R- 01 �2
APPLICATION FOR CITY OF CUPERTINOC."I MBER
REROOF PERMIT
INSPECTION DIVISION PERM,TEKP,RATIDN
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF.PERMIT.ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
- BU/ILLDIINNG ADDRESS BUILDING USE
/ P ®/t.4^/ D!'% �eC RESIDENTIAL COMMERCIAL OTHER
OWNER'S
q HAZARDOUS ROOF
r NAME e,44 � FIRE COVERING
� / AREA CLASS
ADDRESS/ZO '� 7 M 7(/tle �r, �n�.0 EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
—� I // / TO BE REMOVED--/-- TO BE RETAINED
NAME Y f7n Aill"i /1"a y /�DOFy^`,� TYPE OF ROOF COVERING
CITY&ZSF �O `fy5� I1�2`Gl /d-!J (���rlD1 9S EXISTING
f
PHONE
t7 /6!S OCY BUILT-UP ROOF
LICENSEASPHALT SHINGLES
NUMBER 47,pZ rj^D 3 WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
—1 hereto aft I'M that I am licensee under provisions of Chapter 9 (commen
-
ine'with Section 7000) of'DwiSlon 3 of he Business and Pr°feasiont Coda, WOOD SHINGLES
and my IiCenSe it 1 fu f and oid. .
LIO Amy c� ou'"' con Numbe Pix. OTHER (SPECIFY)
Dale �I/�_ Lic.Nu b m
OWNER-8 UILOER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for PROPOSED
the following meson. (Sec. 7031.5, Business and Prm
p ensions Code: Any city
recounty which requ ire5 a permit to construct, eller, improve, deOlish,Or
pair any structure, prior to its issuance,also requires the applicant for such BUILT-UP ROOF
permit to ❑je a signed statement that he Is licensed pursuant to the provisions
Of the Contractor's License Lew (Chapter 9 (commencing with Section 7000)
f m Division 3 or the Business and Professions Code)or that he is exempt there ASPHALT SHINGLES
•I
from and the basis for the alleged exemption. Any violation of Section
1 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more that five hundred dollars($500).1: WOOD SHAKES
❑ I, as owner of the property, ° my employees with wages as pair sole
compensation,will do the work, and the structure is not intended o offered
r tale Sea. 7044, Business and Professions Cotle'. The Contractors License WOOD SHINGLES
Lew does not apply to an Owner Of property who builds Or improves thereon,
and who does such work himself or through his own employees,provided that
Such improvements are not intended ° offeree for sale. If, however, the OTHER (SPECIFY)
building or mprovement is sold within one year of completion, the owner
builder will have the burden of proving that he die not build or Improve for
Purpose of tale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of me property, a exclusively contracting with licensed
contractorz to construct the protect (Sec. 7044, Business and Professions
ode: The ContmctorsLicense Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds Or improves thereon, and who contracts for such projects with a
ontractor($)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under See. ,B,&P.C.for this FASTENER
Owner Date
WORKERS'COMPENSATION DECLARATION
heraby affn
irm that I have a eertifieate of consent to self.insure,or a car- TYPE
Il fica to Of WOrears' Compensation Insurance,or acertified copy thereof(Sec.
Policy Lab.C.1.
Polley No. Company
gCertified copy is hereby nifinfurnished. LENGTH
Ceed copy is filed with me 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 �J `//�/1
lays($100)or less.) VALUATION J D
1 certify that in the performance Of the work for which this permit iz
issued, 1 shall not employ any Par in any m r So s t° subject
10[M1e W°'k��s Cp�pensa[iOn Law f Cali{Orniann ,
Deal rY�"'a`� Applicant
NOTICE TO APPLICANT: If, ter mal ig [M1it Certificate of Exemption, PERMIT FEE'
You should become subject to a W°rka ' Compensation provisions of the
Labor Code, you Tust forthwith comply with Such provisions or this permit
shall be deemed revoked. '/ DATE OF APPLICATION
certify that 1 nave rete this application on ane and that the above races an- �
tion is ws race agree to comply who all city and county ordinances and
slaws rela[ina 10 bpilding <onstmction, and hereby authorize repreven
,lateative5 Of this city t0 enter upon the abovementioned property for inspection
purposes.
(We) agree to Save, indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against liabilities, judgments,costs and expenses which may in any way accrue
st it said City In c nseq nee ening of this permit.
IBnalu t Applicent/Con[rac[or Data
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE h INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY