R-0175.1
PERMIT R_ O f I �J[
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
- } 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
Yr
✓OLfj
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
/"�`�`
HAZARDOUS ROOF
NAME [,L ^�/
FIRE COVERING
AREA CLASS
EXISTING ROOF COVERING
d,I1
ADDRESS �U`/J� r) / n� Aei , J 45 z
21 T 4/0) Z G
NUMBER OF EXISTING COVERINGS
PHONE / O
CONTRACTOR'S
/ l /�)"
/
TO BE REMOVED TO BE RETAINED
�
NAME d / � c7 �-f/�( 61
- TYPE OF ROOF COVERING
ADDRESS,
CITY &ZIP /9fi Jd L/�/v/�� //
-
EXISTING
/JCie �i ill 5'td �`/
BUILT-UP ROOF
PHONE �r z _F,� yL
ASPHALT SHINGLES
LICENSE /
L^
NUMBER /�`
WOOD'SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (comment
v
WOOD SHINGLES
a
ane with section 70oa) Of Division 3 Of the Business end Professions Code,
and my men:$ is in ml r ce and effect.
Ln,crass Lic. Number 1-'
OTHER (SPECIFY)
Date Contracror
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for
PROPOSED
the fallowing reason, (Sec. 7031.5, Business and Professions Code: Any city
Or County which requires a permit t0 construct, alter, improve, demolish,.r
repair any structure, prior to its issuance also requires he 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 (commanding with Section 7000)
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
7031.5 by any, applicant for a permit subjects the applicant to a civil penalty
of not more mat five hundred dollars ($500).):
WOOD SHAKES
❑ 1, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered
for said Sec. 7044, Business and Professions Code: The Contractor's License
WOOD SHINGLES
Lew does not apply to an owner OI property who builds Or improves thereon,
and who does such work himself or through his own employees, provided mat
improvements are not intended or offered ler sale. R, however, the
OTHER (SPECIFY)
,such
uilding or improvement is sold within one year of completion, the owner
improve for
builder will have the burden of proving that he did not build or
purpose of sale.).
PROVIDE LC.B.O. REPORT N0.
❑ I. as owner of the property, a exclusively contracting with licensed
tractor to construct the project (Sec. 7044, Business and Professions
con
ode: The Contracto.'slicenseLaw does not apply toanowner ofproperty
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.&P.C. for his
reason
FASTENER
Ownor Data
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of caused, tirs.H. insure,.
C
/'Q
tific ata of Workers Compensation Insurance, or a certif copy 'hereof (Sea
�a
TYPE ,J�Q/�
3800, Lab. Cd. r4L^'1"�- /
Policy No. Company �i ��i
p�certified copy is hereby fnrnohad'
LENGTH y
Be Celti red copy is filed win he city inspection division.
FEE SUMMARY
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred our
lars ($1Dm or lass.)
GO)
VALUATION S �!/!)• U
that in the performan CO of the work for which this permit is
issued, I shell not employ any person - anyse s to become subject
to the ensati.n Laws offylil /n
Deco ApplicaN ( UG/—
NOTI TO APPLICANT: If, alter making his Certificate of Exemption,
TJ _
�0 .
PERMIT FEEy L/ —
You shoultl become subject to the Workers Compensation provisions of the
.�C�,%/YiG
Labor Code, you must forthwith comply with such provisions or this permit
TE OF APPLICATION
shall be deemed revoked.
I Certify that I have read this application and state that the above informs •
tion is correct I agree to comply with all city and county ordinances and
/
40
state lows relating to building construction, and hereby authorize represen
tatives of this city to enter upon the above-mentioned property for inspection
PERMIT VALIDATION
purposes.
1w.) agree to save, indemnify and keep harmless the City of Cupertino
against liabilities, judgments, costs and expenses which mayd
any way accrue
a n sai tof e erantin m i
am
�
Signature of AppikenUContractor 1/O.W
PRE -INSPECTION
IN -PROCESS INSPECTION
FINAL INSPECTION
REQUIRED
INSPECTIONS
INSPECTOR DATE
INSPECTOR 'DATE
INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR