R-0267PERMIT
R- OZ61
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION . PERMIT EXPIRATION
REROOF PERMIT PERMIT EXPIRES I F WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
- 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
Y�
d 6t— ill
-RESIDENTIAL L"/COMMERCIAL— OTHER
OWNER'S
HAZARDOUS ROOF
NAME ..,/R'yYl //aA,r1 ALGA,/ -
FIRE COVERING
AREA CLASS
EXISTING ROOF COVERING
>f�.
/a�jDG � �"/
ADDRESS ,Io
�%
NUMBER OF EXISTING COVERINGS III
PHONE %e%%"O
✓
CONTRACTOR'S
C�
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
NAME W`{u•t�µ—�(�}/
ADDRESS, i77tifP-%L-G2./
CITU&ZIPS �1G"" 9S//0
EXISTING
PHONE %Cl_/DD
BUILT-UP ROOF
LICENSE i/r' p�
ASPHALT SHINGLES
NUMBER 'ice 4
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 hereby affirmthat licensed unser provisions of Chapter
Professions
WOOD SHINGLES
of s on$(commen
ane with semmn 70001 a1 Division 3 of me Business dna code,.
and my license in ful,f: lid affect j /l�3
.
License lass Lic. Number j 7
OTHER (SPECIFY)
Date Contractor
OWNER BUILDER DECLARATION
I nereby affirm that I am exempt from the Contractor's License Lew for
PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
'
which requires a permit t0 construct, alter, improve, demalish,or
rrecounty
pany structure, prior to its issuance, also requires the applicant for such
BUILT-UP ROOF 7
permit to file a signed statement that he is licensed pursuant to the provisions
I.
0f me Contractor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code) or that he is exempt ,here.
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 that five hundred dollars ($500).1:
WOOD SHAKES s/
In 1, as owner of the property, or my employees with ..,as as their sole
comPpnsetion, will do fie work, and the strucWre is not intended or offeree
for sale (Sac. 7044, Business and Professions Code: The Contractor's License
WOOD SHINGLES
Law does not apply to a r of property who builds or improves thereon,
and was does such work himselfor through his own employees. Provided that
such improvements are.not intended or offered for sale. If, however, the
OTHER (SPECIFY)
building or improvement is sold within one year of c mpletion, the owner
builder will have the burden of proving that he did not build or Improve for
purpose0+eele.).
PROVIDE LC.B.O. REPORT N0.
❑ I, a of the property, a exclusively contracting with licensee
contractors to c construct the project ISc. 7044, Business and Professions
Coda: The Contractor's License Law does not apply to an owner of property
PROVIDE MFGR.INSTALLATION SPECS.
who builds or improves thereon, and who connects for such projects with a
contractor(s) licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. ,B.&P.C. for thisreason
FASTENER
Owner Date
WORKERS COMPENSATION DECLARATION
'
I hereby affirm that I have a certificate of consent to self insure, or a car.
a
TYPE L!i
tifica to of Workers' Compensation lesul�n cerli lied copy thereof (Sec.
,
/ y
3800, Lab. s� /`��
Policy No L ���r CompanytAA[fA✓
Pant/I
❑ Certified copy is hereby furnished.
LENGTH �-
py) ly w yM1'i cfy division,
FEE SUMMARY
Ain
le
App�C6eititie A
.
CERTIFICATE O EE PTI ON FR��//OM WORKERS'
0JJ
COMPENSATION INSURANCE
Y
(This section need not be completed if the permit is for One hundred dol
.. • 1 )
lots IS 1 orless.)
VALUATION
I certify that in the performance of the work for which this permit Is
-
n
-Issued, I slrall not employ any person In any manner so az to become subl Oct
to the Workers' Compensation Laws of California:
-
Date Applicant
NOTICE TO APPLICANT: It, after making this Certificate 0f Exemptlon,
PERMIT FEE u�f LSE Afi`'/ �+ S'TJ
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
DATE 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
x1.20 laws relating to building construction, and hereby authorize represom
tatives of this'city to enter upon the above mentioned propef ty for inspection'
PERMIT VALIDATION
purposes.)y i
(We) agree to save, indemnify dna keep harmless me city o1 Cupertino
again at Iia bili lies, I dgmen ts, costs and expenses which may in any way accrue
.gaunt saitl City Irt comarinen of th granting of this pe i
p
/
5�9net.,entf APPiicen HComrectof Oate
PRE -INSPECTION
IN -PROCESS INSPECTION
FINAL INSPECTION
REQUIRED
hINSPECTOR
INSPECTIONS
DATE
INSPECTOR DATE
INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY