R-0168 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Ras O1 (;V S
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
',;`.a''•'+ WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
••. BUIILLDIIN/;GGADDRESS - \ BUILDING USE
' 1 I "l� 1 M ( RESIDENTIAL „y/ COMMERCIAL OTHER
OWNER'S -1(� (�
ROOF
NAME �C) iJ C/ /� fl-IJ I_ �. FIREAR HAZARDOUS COVERING
�.� ^ AREA- CLASS
y ADDRESS -7U m PK � N �V- EXISTING ROOF COVERING
PHONE — 72 NUMBER OF EXISTING COVERINGS '
CONTRACTOR'S
Se 1 � TO BE REMOVED� TO BE RETAINED
NAME - TYPE OF ROOF COVERING
ADDRESS,
CITY&ZIP EXISTING
BUILT-UP ROOF
PHONE
. LICENSE•, ASPHALT SHINGLES
'NUMBER.,
- , WOOD SHAKES -
LICENSED CONTRACTORS under DECLARATION
with S affirm On0O I of licenses under e Business
of Chapter 9 ons(common.
mg with Section 7000)force
Division 3 of Ina aasmess and Professions code, WOOD SHINGLES lL
and my license is in fou tome ens effect.
License Class- ContraOTHER (SPECIFY)
. Date Contractor mpr
OWNER BUILDER DECLARATION
Ihereby affirm that I am exempt from the Contractor's License Law for PROPOSED
,he fallowing re (Sec. 7031.5, Business and Professions Code: Any city
or county which ,requires a permit to construct, alter, Improve, ded isb,or
repair env structure,prior to its issuance, also requires me applicant for such BUILT-UP ROOF
_ permit to file a signed statement that he is licensed pursuant to the provisions
YG of in Contractor's License Low (Chapter 9 (commencing with Section 7000)
Ot Division 3 of One Business and Profession,Code)or that he is exempt mere ASPHALT SHINGLES
Irom and me basis for [M1e allegatl iexem PtiOn. Any vi ola[ion bol Sact[an
• �. 7031.5 by any applicant for a permit .bloc is me applicant to a civil penalty
..1_:., of not more that five hundred dollar,(5500)7: WOOD SHAKES
❑ I,a owner Of the property,0 my employees with wages as their sole
compensation will do the work, andthestructure is not intended or offered WOOD SHINGLES u
for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law tloes not apply 10 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 ror
offered for sale. If, however, the OTHER (SPECIFY)
building o improvement zona within one veal of c mpletion, me owner.
builder will have the burden Of proving that he did not build Or improve fOr
p sapesdli � �' PROVIDE I.C.B.O. REPORT NO.
1, s r o1 the property, am exclusively contracting with licensed
ectprs to of
the project (Sec. 7044, Business and Professions
c de: The Contractor's License Law does not apply to an owner of property
C
builds or improves thereon, and who contracts for such projects with a PROVIDE MFG R. INSTALLATION SPECS.
contractors)licensed pursuant to the Contractor's License Law.'
0 1 am exempt under Sell ,B.&P.C.for his
FASTENER
jow�e I Date -
I +J WORKERS'COM PENSATIO EC sent to ON /
to of affirm that l neve a certificate Of consent ie self-insure,r o a cer. TYPE Al-Al
3 00, of Workers' Compensation Insurance,o ertifiad,copy thereof ISef.
380q Lab.CJ.
Policy Certified
Company It
Certified copy is hereby w furnished,cit. n LENGTH
Certified copy is filed with me city Inspection division. ,
Applicant FEE SUMMARY
CERTIFICATE ON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be be completed
COmplatetl it the permit is for one hundred tl01-
Iar,(srom o.less.) (VALUATION
1 certify that in tho performance of my work for which this permit i,
issued,theWorkers'
'C employ any person any manner so a,10 become subject \ ,
to the Wprkarz'Compensation Laws of California.n
Dale Applicant
NOTICE TO APPLICANT:T: o after making this Certificate p of Examen of
fithe PERMIT FEE 3.2
Von
should become mo st fort to 1M1c Workers' Comph such provisions
provisions of the
Labor
tiCode,
reacted�a must forthwith
ormwnn comply with such provi:ion,or this permit DATE OF APPLICATION
I certify that I have read this application and state that the above intorma
Pon is correct. I agree tocomply with all city and county ordinances and
state laws relating to building construction, and hereby authorize represent
[ativez of this city to enter upon the above mentioned property for inspection
purposes.
We) agree to say indemnify and keep harmless the City of Cupertino _ PERMIT VALIDATION
ag b'ides, I dgm costs and p mass which may in any way accrue' -
nat City in pn ence c fA-I the a ing of this 277
er [.
a
C)
/S n 1.,001 Applicant Contractor Datais
IL
REQUIRED PRE-INSPECT N 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