R-0195 OMBERR-saRMIT 0 1 �[APPLICATION FOR CITY OF CUPERTINO J
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
PERMIT EXPIRES I F WORK IS NOT STARTED
WITHIN 18D DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
`*
BUILDING ADDRESS D / /\� BUILDING USE
/OI l / T"' L/�r RESIDENTIAL COMMERCIAL OTHER
OWNER'S
Y /rte— w.t / HAZARDOUS ROOF
NAME
FIRE COVERING
AREA CLASS
ADDRESS7� c ., EXISTING ROOF COVERING
PHONE/ Jr O Z NUMBER OF EXISTING COVERINGS
`f CONTRACTOR'S
. TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADDRESS,
CITY a ZIP EXISTING
BUILT-UP ROOF
PHONE
LICENSE ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I With
affirm that of Division
3 .1under provisions of Chapter Professions
s(common
cing y license
enation wool force
and en 3 of me apsme:,and Prp(nssmps epee, WOOD SHINGLES
and my license is in Lull lorce ane effect.
License Class Lic.Number
Date Contractor OTHER (SPECIFY
OWNER BUILDER DECLARATION
I harebY affirm that I am exempt from the Contractor's License Law for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
linty which requires a permit t0 construct,alter, improve, deol or,or
repaym
env structure, prior to its issuance also repairers 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 mat ne is exempt mer¢ ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
.'�F. 7031.5 by any,applicant for a permit subjects the applicant to a Civil penalty
of not more that five hundred dollars($500).): WOOD SHAKES
❑ 1, as owner of the property, or my employees with wages as their sole y
compensation will do the work, and the structure Is not intended or offered WOOD SHINGLES
for sale (Sec. 7044, Busctor's i pass and Professions Code: The ContraLicense
Law does not apply to a of property who he Ids or improves thereon. -
and Who dues such work himself or through his own employees,provided that
such improvements are not intended o offered for sale. I1, however, the OTHER (SPECIFY) F
bu ildin mprovement is sold within or
a year of c mpletion, the o
y b 'de wild M1ava iM1¢burden of proving[M1et M1a die not build or improvefor
P. O of sale.). PROVIDE LC.B.O. REPORT NO.
sl, az owner of the property, am exclusively contracting with lic.nsed
co tr dors to construct the project (Sec. 7044, Business and Professions a
de: The COntrat[Or's License Law goes not apply to an owner Of properly PROVIDE MFGR. INSTALLATION SPECS.
he builtls Or improves thereon, and who contracts for such projects with a
tol(sI IiCenzetl pu rsuanl t0 the COnlr9etOr's License Law.
p p pt under see. ,B.&P.C.for his FASTENER
owe o� Dam. 1
WORKERS'COMPENSATI DECLARATION
hereby affirm that have a certificated consent m self-insure,or a a<r. TYPE
illi cat.of Workers' Compensation Insurance,or a certified copy thereof(Sec.
3800, Lab.C,).
Policy No. Com pant/
gCartified copy is hereby furnished.
Cn LENGTH
ertified copy iz hled with the city inspection division.
Applicant ? FEE SUMMARY
CERTIFICATE COMPENSATION
FROM WORKERS'
COMPbe completed
ON INSURANCE �.n.( _
(This($ 0 section need not be<ompletetl it the permit is for one hundred dol-
lars($100)or that
i VALUATION
certify tnu In ma performance of the work for aswhich this pe subject is
sou ad, 1 shall net employ any person in any manner so as to become subject
To
Na Workers'Compensation Laws of California.
Oa[eApplicant �/��///)\
NOTICE TO APPLICANT: If, after making this Certificate of Exemption. PERMIT FEE' J✓
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions Or this permit
shall be deemed revoked. DATE OF APPLICATION
• certify that I agree
metl this application and stem that the above informs
sand /�`
Lipo ctifyt correct. I agree to comply with all city and county above info end
state laws relating to building construction, and hereby authorize represem /
tatives of this city to enter upon the above-mentioned property for inspection
purpose'(We) agree to save, indemnify and keep Harmless the City of Cupertino PERMIT VALIDATION -
against liabilities,judgments,costs and expenses which may in any Way accrue
against said Cit in consegoence of the granting of this permit.
Signa a of Applicam ontra
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION - FINAL INSPECTION
INSPECTIONS1 IINSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY