R-0117 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMB R R- 0117
INSPECTION DIVISION PERMIT e REROOF PERMIT PERMIT ES IF WORKIS NOT STARTED
WITHIN 1S80 DAMS OF PERMIT ISSUANCE OR
180 DAYFROM
LAST CALLED INSPECT ION.
. T BUILDING ADDRESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
U HAZARDOUS ROOF
\NAME FIRE COVERING
AREA CLASS
EXISTING ROOF COVERING
ADDRESS
,S 7 — 1 NUMBER OF EXISTING COVERINGS
PHONE /
CONTRACTOR'S
' TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADDRESS,
CITU& ZIP /�/ EXISTING
PHONE�% 4/— /la�S - BUILT-UP ROOF
/I •LICENSEo�/// ASPHALT SHINGLES
/ NUMBER o! (0.J WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 hereby affirm than am licensed under Provisions of Chapter 9(common- WOOD SHINGLES
left with Section )000) of Division 3 of the Business and Professions Code,
and my license isful.foy® all
nd act. .Z/
License Class N/ Lic.Numbm'�//�S
Date // (iT s Contractor elf-u--` — OTHER (SPECIFY)
'T6�Z OWNER BUILDER DECLARATION
I hereby 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
i recounty which requires a permit in Constm et, alter, improve, demolish,Pr r
pany structure, prior to Its issuance, also requires me applicant for such BUILT-UP ROOF
Panel t to Lila a signed statement that he is licensed pursuant to the provisions
.✓:. of the Contractor's License Law (Chapter 9 (commencing with Section]000)
of Division 3 of the Business and Professions Code)or that he is exempt there ASPHALT SHINGLES
�•- from and the basis for the alleged exemption. Any violation o1 Section r -
7031.5 by an V,applicant fpr a permit be bice is ma applicant to a Civil pan at Ty
that
of not more t rvehunared dollars($50oJ.1: WOOD SHAKES
❑ I,a of the property, o my employees with wages as their sole
fompensatioon will doi work, andthestructure Is not intended or offered WOOD SHINGLES
r sale (Sec. 7044, Business and Professions Code: The Contractor's License
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
to ch Improvements are not intended or
offered dow
r sale. If, however, the OTHER (SPECIFY)
building o improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
purposeat sell.). PROVIDE LC.B.O. REPORT NO.
❑ I, as owner of the property, a exclusively Contracting with licensed
contractors to Construct the project (Sec. 7044, Business and Professions
Code The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who contracts for such projects with a
conkactm(s)licensed pursuant to he Contractor's License Law.
Ij 1 am exempt under Sec. ,B.&P.C.for this FASTENER
mason
Owner Date -
WORKERS'COMPENSATION DECLARATION
/I hereby afflml that I nava a Certificate of consent to self.i more,or a orTYPE '
tlficate of IN kart Compe9 t!/on iInsu[ f' r a erti fletl�Qpy thesrf(Sec
13800, Lab�).� i1
Polity N / puny Q- f
'
Certified Copy is sfurnished. LENGTH '
�
Certified copy is with the ev Inspection aiyisioCertifiedreedled w
Applicant FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE C -
(This section need not be completed if the permit Is for one hundred dol-
lets 1$100)or less.) VALUATION 7—
I certify that in the performance of the work In, which this permit is T
issued, I shall not employ any person in any manner so as to become subject
to the Workers'Compensation Laws of California. -T
1' Date Applicant p
( NOTICE TO APPLICANT: If, after making this certificate Of Exemption, PERMIT FEE (a� . kTi`7/C., 4
you should become subject to the Workers' Compensation provisions of the
Labor Code, you mus[ forthwith comply with such provisions Or [els Permit
shah bedaemed revoked. DATE OF APPLICATION
I certify that I nave read this application and state that the above internal
tion is correct. I agree to Comply with all city and county ordinances and -
state laws relating to building construction, and hereby authorize rebresen-
tativers of this city to enter upon the above mentioned Property for inspection
our WC) y PERMIT VALIDATION
WC) agree to save, indemnify and keep harmless the City of Cupertino '
age st liabilities,judgments,costs and expenses which may in any way accrue
rYI og IT oldity in C s quence of the granting f th' Permi I. -
7(\�}
M;� Sig dor 1 Applice Comrasvor De
REQUIRED L
, - 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