R-0171 PERMIT R_ O
APPLICATION FOR CITY OF CUPERTINO NUMBER r
INSPECTION DIVISION PERMIT REROOF PERMIT PERMIT ESIF WORKIS NOT STARTED
WITHIN 180 DAMS OF PERMT ISSUANCE OR
180 DAYS FROM LAST CALLED
INSPECTION.
•-
BUILDING ADDRESS BUILDING USE
Po�Pyw � \' 1C%1VT) �Jo. RESIDENTIAL COMMERCIAL OTHER
OWNER'S !� �J� {�
P-. CV, T• ZAV— 1�-- HAZARDOUS ROOF
NAME FIRE COVERING
1I2 AREA CLASS
ADDRESS l EXISTING ROOF COVERING
PHONE — NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOV ED--K— TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADDRESS, EXISTING
BUILT-UP ROOF
PHONE
LICENSE ASPHALT SHINGLES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(comm an
twith Section 7000) of Division 3 of the Business and Professions Code, WOOD SHINGLES
cum It
and my license is in full force and effect.
License Class Lic.Number
Date Contractor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the following res (Sec. 7031.5, Business and Professions Code: Any city
or county whichrequires a permit 10 construct, alter, improve, demolish,Or
repair any structure,prior to its issuance,also requires the applicant for such BUI'LT�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
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 F
,•.
.1 no, .,.mat live hundred dollars( 500).): � WOOD SHAKES
I, as Owner of he property, Or my employees with wages as their sole
saaon,wi11
704r
do tna work, and he structure is not intended or of+ered WOOD SHINGLES X
for sale (Sec. 4, Business and Professions Code: The Contractor's License
Law does not apply t0 an owner of property who builds or improves thereon,
and who does such work himself or through his Own employees,provided that
such improvements a not intended or offered for sale. If, however, the OTHER (SPECIFY)
build l ng o mprovement is sold within One year Of completion, the owner.
builder will have the burden of proving that he did not build or improve for
Purpoaee'aale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, a r of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
ode: The Contractor's License Law does not apply to an owner o+properly PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who contracts for such projects with a
contractor(s)licensed pursuant to the Contractor's License Law. f
❑ I am exempt under Sec. ,B.a P.c.mr this FASTENER
\oease ,�
wns Date
WORKERS'COMPENSATION DECLARATION
_ I hereby affirm that I have a certificate of consent to self unsure,or acer. TYPE ill.—Y Al L..,
Iili.ha Of Workers' Compensation Insurance,or a certified copy thereof(Sec.
3800,Lab.C.).
Policy No. Company
SCertifiad copy is hereby boon m. LENGTH .
Certified copy is filed with the city Inspection division.
Applicant _ - FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is one hundred 001- L
hus($100)or less. ) VALUATION�Cl
I certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner so as t0 become subject r
to he Workers'Compensation Laws of California.
Do'
e - Applicant
NOTCE TO APPLICANT: If, after making this Certificate of Exemption, PERMIT FEE 31 SCx/`7
I 7 C
you should become Subject t0 the Workers' Compensation provisions of the 'k
Labor Code, you must forthwith comply with such provisions or this permit
shall be deemed revoked. DATE OF APPLICATION
I certify that I have read this application and state that the above infprme `
tion is correct. I agree t0 comply with all city and county ordinances and
state laws relating to building construction, and hereby authorize represent- o �f
tatives of this city to enter upon the above mentioned property for inspection
purposes. v PERMIT VALIDATION
.(Wel agree to save: indemnify and keep harmless the City of Cupertino
gainrt liabilities,judgments is d expanse which may in any way accrue
t said City In f e granting this permit.
� _ it permit,$ e of Applicant/Contracto Deter
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