R-0160 PERMIT R_ 0160
APPLICATION FOR CITY OF CUPERTINO NUMBER
R—
REROOF PERMIT
INSPECTION DIVISION �/ PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
e WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
-'� BUILDING ADDRESS - ' ,BUILDING USE
RESIDENTIAL V/COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME FIRE - COVERING
AREA CLASS
/ ADDRESS �7 EXISTING ROOF COVERING
PHONE / b 2-- NUMBER OF EXISTING COVERINGS r
CONTRACT , /
TO BE REMOV ED._JL- TO BE RETAINED
NAME OR' � TYPE OF ROOF COVERING
ADDRESS, Z� � S EXISTING �,/
CITY&ZIP 1 ,i
� 11 . I BUILT-UP ROOF
PHONE 7 7�� �a_s
LICENSE1 . ! cf ASPHALT SHINGLES
NUMBER W b
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 1
Fine with.Sectmq 70001 f Dimsion 3 of he Business and Prgrassiq,l,_gao, WOOD SHINGLES
and my IiF nso is pptull foff��@@ y96L�Ifoct
License Clesz�`— Lia Number (e Q_
Data .A—;Z:— Contra OTHER (SPECIFY)
six x"iO E -BUILDER DEC LA A N
I heroby affirm that I am ...rept from the Contractor's ansa Law,or PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code::Any city
Or county which requires a permit to construct, alter, improve,demolish,°r
repair env also=tore. Prior t° its issuance also requires the 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 (commencing with Section 7000)
of Division 3 of the Business and Professions code)or that he is exempt mere" ASPHALT SHINGLES
'.' Isom and the basis for the alleged.exempts the
Any violation of Section
f 7031.5 by he applicant and ter a permit exemption.
the Anycontvio to a civil penalty
of not mesa that five hundred dollars($500)1: _ WOOD SHAKES
❑ I,as owner of the property, or my employees with wages as their sole
focompensation,will d0 the work, and the structure is not intended o offered '
r sale (Sea. 7044, Business and Professions Code: The Contractors 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
such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building O nemovement is sold within one year of c mpleti°n, the owner.
bull dor will have the burden of proving that he did not build or improve for
purposeC] I a'olwne PROVIDE I.C.B.O. REPORT NO.
❑ 1, r construct t IM1e properly, a eclu 044, convecting with wens s
ode: he Ctracor'sthe project (Sec. t app Business and Professions
code: The Contractor's License Lawand w o cot apply foe such
je Property PROVIDE III INSTALLATION SPECS.
who actors o reproves thereon, and who actor's Li for such parole=¢with a
contractors)licensed pursuant to me Contractor's License Law.
❑ 1 am axarepl under sea. ,B.a P.c,for this FASTENER
.ason.Pat
Ow Date
I WORKERS'COMPENSATION DECLARATION
to ON
hereby affirm that 1 nava i certificate , consent ie cap,Cher°racar. TYPE
3800,4 of Workorz' Compensation Insurance,or a certified copy thereof(Sec.
380q Lab.CJ.
Policy No. Company 2-
Ce
7 X
OCertified aopv Is hereby with the cit LENGTH
Cortitied copy is tiled with,M1e city inspection division.
AppOcont FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section head not be completed,if ,M1e permit is for one hundred do' �-
lare($1 DO)0r less.l VALUATION , 00 0
I certify that in ,M1e performance of the work for which this permit is
issued, I Shell not employ any person - any on er so as,° ub ac
t0 the Workers'Cor9pgpee,ion L.
f eilornienn s e ore �J
Date/ 7�A Applicant �-T
you
ld PP Nec U, aftor aks' this }of f Ex lion, PERMIT FEE V ' .Se/fMJC 0C9
you shoved become subject to the Workers' comp sari° provisi of the
tali on deemed you
ed forthwith comply with sue provisions or mid permit% DATE OFIIAPPLI CATION
Shall I certify that I have read this application and state that the above informs h
tion is correct, I agree to comply with all city and county ordinances and -
state laws relating to building construction, and hereby authorize represom
latices of this city t0 enter upon the above mentioned property,Or inspection
purposes.
(We) agree to s indemnity and keep harmless the City of Cupertino PERMIT VALIDATION
against liabilities, judgments,costs and expenses which may in any way accrue
age at said City in c°nsequ oc o,me granting of this permit
',�t ig eture bi AP scan I Sic
n sac Dale _��_�� \/y7-'°( /V//-'•1 /��
' REQUIRED O -INSPECTION IN-PROCESS INSPECTIONFINAL INSPECTION
INSPECTIONS1 IINSPECTOR DATE INSPECTOR - DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY