R-0132 PERMIT 0132
APPLICATION FOR '; CITY OF CUPERTINO NUMBER R
REROOF PERMIT 5 INSPECTION DIVISION PERMIT EXPIRATION
PERMT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCEOR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - BUILDING USE
/D N RESIDENTIAL COMMERCIAL OTHER
OWNER'S4/ e
ROOF
NAME
//21L 14f IAC ?►-� FIREAR HAZARDOUS COVERING
AREA CLASS
ADDRESS S
EXISTING ROOF COVERING
a �' � I
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S Y _ 7 j
AZTO BE REMOVED TO BE RETAINED
O S S T q�fPl�
NAME P TYPE OF ROOF COVERING
ADDRESS, P1 ��/� L ru�,�N
CITY&zI��P// OC 7 ''//^ �!!! IY/ ,C7� C EXISTING -
ti PHONE T — 7'J /2I / BUILT-UP ROOF
LICENSE ��Q�� / ..r+ ASPHALT SHINGLES
NUMBER / WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
with affirm that) of licensed under provisions of Chapter 9(cathode,
ing with Section 7orm or Division 3 of the Business and Professions cmc, WOOD SHINGLES
and my license isin 07porce and effecte OJ��
License class C
Date Contractor
tractor Number OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I a rout from he Contractors Leanne Law for PROPOSED
o
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
rePerry which requires a permit to c nstruct, alter, improve, dem Olish,or
paany structure, prior to its issuance also requires the applicant for such BUILT LT-UP ROOF
' parmit to+le a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing 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 permitublects the applicant to a civil penalty
of not mora that five hundred dollars($5om. 1: WOOD SHAKES
❑ 1, a owner Of the property, ormy employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered
for sale (Sec. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
Law 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
uch improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year of ca mpletion, me o n
builder will have the burden of proving that he did notbuild Or improve for
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
C] a
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.
wee 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.•tor this ason FASTENER
,-be Data
WORKERS'COMPENSATION DECLARATION - 1 .�, Y/
1 hereby affirm that 1 have a certificate of consent to selunsura,or a car. TYPE f���S /L�'��-
tificate of Workers' Compensation Insurance,or a certifi ddccopy thereof(Sec.
Policy Lab.Q). Company
S�P�P ' //
Poli No. Co
❑ eaauiad copy is her by m. shed. ' LENGTH /�//(l
ea�tenniee copy is sled with he city inspection aivi:ion.
Applicant FEE SUMMARY
CERTIFICATE E EXEMPTION FROM WORKERS'
COMPENSATION completed
ON INf tRANGE
(This section need not be completetl if [M1e permit is for one hundred dal- /_1 oOO
Ida(sero)or that in
VALUATION (�
I certify mat in theemploy
performance of the work for which this permit is
issuetl. I shrill n01 employ any parson in any manner so az to become subject
to the Workers'Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If.o after making this Compensation
p of Ex empfiO a PERMIT FEE
you should become subject i me Workers' Compensation provisions a me
Labor dee you mull forthwith comply with such provisions or this permit
shah be deemed revoked. DATE OF APPLICATION
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 I ^ [s
state laws relating to building consvuction, and hereby authorize nepresem L J\
tatives 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
ga s���...111sssaaa-���-III ties,iue9ments,cost/eye expenses which may in any way ace tae
a tl City In consequ f9ha grantin,of this Permit.
L�Eerfjna ure of Applicant/Contractor Date
REQUIRED PRE-INSPECTION 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