R-0162 PERMIT (;
APPLICATION FOR CITY OF CUPERTIIy(1(J[/'V� NUMBER R- 0162
REROOF PERMIT INSPECTION DIVISIO / " PERMIT EXPIRATION
v PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE -
O J�7 /T Es RESIDENTIAL /COMMERCIAL OTHER
OWNER'S
NAME L� / �EI-Si/C/�
HAZARDOUS ROOF
FIRE COVERING
AREA CLASS
ADDRESS ��MC - EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /
NAME C� Gs// /I.Q. �noF//✓lv TO BE REMOV EDI-PTO BE RETAINED
// TYPEE OF ROOF COVERING
ADDRESS
CITY&Z -3 Yr<.J !/ i/e- S/ EXISTING
SAn/Tf? L/ C //eA� 9SOS BUILT-UP ROOF
PHONE
LICENSE ASPHALT SHINGLES
NUMBER Z WOODSHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions Of Chapter 9(common.
emg with Section 7000) of Division 3 of the Business and Professions Code, WOOD SHINGLES
nd my license is Lill f and effect
License
c Contractoer 6 y N(>, OTHER (SPECIFY)
OWNER BUILDER DECLARATION 1
I hereby affirm that I am exempt from the Contractors License Law for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code:.Any city -
recounty which requires a permit construct, alter, improve,dem Olish,Or
pay W any structure. prior 10 its issuance also requires he applicant far such BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions _
of the Contractors License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Coda)or that he is exempt there ASPHALT SHINGLES
1 from and the basis for the alleged exemption. Any violation of Section V
- 7031.5 by any applicant for a permit subjects the Applicant U,a civil penalty
•,
of not more that five hundred dollars( 500).): WOOD SHAKES
❑ 1,as owner of the property. Or my employees with wages as pair sole
compensetipn,will d0 the work, and the structure is not intended o offered
F.r sale (Sec. 7044, Business and Professions Code: The Contractors License WOOD SHINGLES
Law does not apply to an owner Of property who builds 0r improves thereon,
and who does such work himself or through his Own employees,provided that
such immoements are not intended 0r offered for sale. It, however, the OTHER (SPECIFY)
builtling o improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or improvefor
pu,paseat Sale.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, aowner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Cade: The Contractor's License Law does no,apply toan.,herofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or mproves thereon, and who contracts for such projects with a
cont/actim(s)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt ender Sec. ,B.&P.C.for thisreason - FASTENER
Ow Data
nor WORKERS-COMPENSATION DECLARATION
I hereby affirm that I have a
lycertificate of consent to self insure,or car YPE
tificute of Workers Comp enapt a Insurance, r tilled Copy Thereof(Sec.
Policy .I ,).
Poo hloLab C, O//7) C d GC Cy !`,, y�
$ certified copy is hereby furnished. LENGTH r
p"Cernfie't(m.S iIp with he city in tion don division.
Applicant CStO ; /CiJeF'N FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION NSURANCE ,
(This section need not be'completed if the permit is for one hundred doh
ISIS($100)or less.) VALUATION
I certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner so as to become subject
to the Workers Compensation Laws of California. j
Data Applicant fi
NOTICE TO APPLICANT: If, site, making this Certifiaatao1 Exemption, i PERMIT FEE
you should become subject to the Workers' Compensation prov inions of the
Labor Code,you must forthwith comply with such provisions or this permit
Shall be deemed,evoked. 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
state laws relating to building construction, and hereby authorize represeln
natives 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
against liabilities, judgm is osis antl expenseswhich they In ny way accrue
again itl City m con ce Of the granting Of this perm'
m s s S
Si store of plicAnt/DOpbdp
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