R-0218r
PERMIT R_ 0218
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
f
RESIDENTIAL i-i""" COMMERCIAL OTHER
OWNER'
HAZARDOUS .ROOF
NAME FIRE COVERING
, AREA ' CLASS
ADDRESS,fi .,� �A'�Q EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACT R'
r � � TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
ADDRESS,
CITY&ZIP L.� fi
. EXISTING
PHOND „ �5 BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
hereby affirm 70001 of Division
under a Business
pt Chapter 8(cpmmen. WOOD SHINGLES !�
ing with Section ]000) of Division 3 of the Business entl Protezzions Coati,
and my license i II i entl effect
License Cl ass Con Number l:a�P-�������� OTHER (SPECIFY)
Dam g%/4 n ' Contractor 7
OWNEnd exemUI pt
from the RATION
I hereby affirm that am exempt from Business a Contractor's License Law for PROPOSED
the follows ng reason. (rept. permit, conentl Professions veae: Any city
rpecounty wM1IcM1 rep pries a permit to construct,re alter, improve, tla for
rmi any structure,lign prior to its issuance,h ei also sed Pur that to the
for span BUILT-UP ROOF
of the to the signed eseLastatement that he is licensed pursuant it tSe provisions
of the Contractor's3ofthe License Law (Chapter s (commencing with islkenion 7000)
from
Division a of me Business and alleged
exemption.
conal or mat he is exempt mare' ASPHALT SHINGLES
Loth entl the basis for the allermi exemption. Any ant to
vi Section
of not by any.applicant for a permit subjects the applicant to a civil penalty
+,-- of not more that rive the pro dollaerty, my em 'WOOD SHAKES
• kir"' ❑ I, as owner of the property, o my employees with wages as Moir tole
lemole (Soon, will do thesin work, andthestructure Is not intended Contractor's offered
r sale Isec. ]044, to neo entl Professions Cotle: The orimpryesLicense WOOD SHINGLES
Lew does net apply to a of progeny who buildsorimproves thereon,
and improvements p es sect work not inter ed or offered
niz own employees, however.
owl vetl mat
suer goriprovare not intended with or oe year
for sale. H, npthe owner OTHER (SPECIFY)
builder il mer t e bur is sold within one year of c muild or the
builder will have the burden of proving that he tlitl dol build or improvefor
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
C] I, as owner of the property, am exclusively contracting with licensed ,
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Conacto:sLicense Law does no,apply 1.anowner ofproperty pROVIDEMFGR. INSTALLATIONSPECS.
who builds or improves thereon, and who contracts for such projects with a
contractor bl licensed pursuant to the Contractor's License Law.
❑reason1 am exempt under See. ,B.&P.C,for this FASTENER
Oei Dote
ter WORKERS'COMPENSATION DECLARATION
1 hereby orfnm that have i certificate or consent self insu.e,o TYPE
,,cats of Workers' Compensation Insurance,or ancertified,c[o�py thereprf(Sec.
0800,Lab , t�' b�— C•A./ ,l
Policy No.c 1T Oq Company / f
�[r71 Certified copy is hereby furnished I , LENGTH
ApT)lic Carl red copy's rhes:m t ity i�ss�pe�'p p on.
CERTIFICATE 0 EX MPTIOWFRR`Oj WOORKERRS FEE SUMMARY
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred Col /'
lots(5100)or less.) VALUATION `7 G xG'
I certify that in the performance of the work for which this permit i's
ped. I shall not employ any person in any manner so as to become subject
to the Workers'Compensation Laws of California. '
Dale Applicant C+
NOTICE TO APPLICANT: 11, after making this Certificate of Exemption, PERMIT FEE J�`��'//G. %5-0you should become subject to the Workers Compensation provisions of the
forthwithLabor Code, you must comply with such provisions or this permit
mall be deemed revoked. DATE OF APPLICATION
I certify that I have read this application and state that the above informa
tion is correct. I agree to comply with all city and county ordinances and
state laws ielming to building construction, and hereby authorize represen
[atives Of In city to enter upon the above mentioned property for inspection
o Pl s.'
(We) Ilene to save, indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against liabilities,judgments,costs d expenses which may In any way accrue �
IT againstlnLt i [pni once oft 9r 9 of in`permit.���
/ Signature pf Al tic nt/Conn c[Signature Al 1Ic nr/Conn ct
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