R-0258°rvl'r
PERMIT R—
R—
APPLICATION FOR CITY OF CUPERTINO NUMBERO25V
PERMIT. INSPECTION DIVISION -PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
(I�
9 V
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME
FIRE COVERING
AREA CLASS
EXISTING ROOF COVERING
ADDRESS � �-�
NUMBER'OF EXISTING COVERINGS
PHONE
CONTRACTOR'S
n ^
TO BE REMOVED TO BE RETAINED
NAME e
TYPE OF ROOF COVERING
ADDRESS,
V
CITY & ZIP
EXISTING
BUILT-UP ROOF
PHONE f'7 h
ASPHALT SHINGLES
LICENSE�b �_�
NUMBER
WOOD SHAKES 40
LICENSED CONTRACTORS DECLARATION
hereby that I am licensed under provisions of Chapter
7
WOOD SHINGLES
Code,
Section s ons(comm
Professions
cine y with license uil r Division 3 of me Business and Prmessmnz code,
.��i_� /
and my boon.. ull.{b and affect. 4�-(� s – jT
License nays
Con Number
Dery P'; Contracto.
OTHER (SPECIFY)
W ER -BUILDER DECLARAT N`f
1 hereby affirm that I am exempt from the Contractors License Law for
PROPOSED
the following reason.(Sac. 7031.5, Business and Professions Cotle: Any city
or county whichrequires a permit to construct, alter, improve, domolish,or
'
repair any structure, prior to 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 there.
ASPHALT SHINGLES
fir In 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
of not more that five hundred dollars ($500).):
WOOD SHAKES
[3I, as owner of the property, ormy employees with wages as Ih.ir sole
compensation, will do the work, and the structure is not intended or offered
for sale (Sec,. 7044, Business and Professions Code: The Contractor's License
WOOD SHINGLES
Law dons not apply to an ownerof property who builds or Improves thereon,
and who does such work himselfor through his own employees, provided that
imrovements are not intended o offered for sale. I,, however, the
p
OTHER (SPECIFY)
buimiacM1
n9 o Improvement is sold within o e year of c mpletion, me owner
builder will ave the burden of proving that he did not build or improve for
purpose of `o�.no
PROVIDE I.C.B.O. REPORT NO.
Cl as of the property, am exclusively contracting with licensed
contractors to c nstruct the Project (Sec. 7044, Business and Professions
Code: The Contractors License Law does not apply to an owner o, property
PROVIDE MFGR. INSTALLATION SPECS.
Who builds o mpmves thereon, and who contracts for such projects with a
contracmr(s) licensed pursuant to the Contractor's License Law.
❑ l am exempt ender Sec. ,B.&P.C. for this
FASTENER
Owne Oat.
WORKERS' COMPENSATION DECLARATION
1('� /�
hereby affirm that have a certificate of consent to self insure, a car .
TYPE_ 9I
tificete of Workers' Compensation Insur ce, or a certified copy erect 1
e
—
/
3800• Lab.. pG Y
Policy No -1 S� o@p'any S
C.hfli.d copy is hereby f„rni:had. I
.`
LENGTH r Y
Certified copy is 111eq•,��m t t anion division.
Appbcent �/�/—!>��
_ FEE SUMMARY
CERTIFICATE OF ROM WORKERS'
COMPENSATI O NINSURANCE
(This section need not be completed if the permit is for one hundred dol.
�I -
lars ($1001 or less.)
VAILLATION,
1 certify thrmne
at In the perfoacof the work for which this permit is
issued, I shall not employ any person in any manner so as to become subject
to the Workers Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: Ii, atter making this Certificate of Exemption,
JZ
PERMIT FEE �`�'� f X`'� X �• / S a
you should become subject to the Workers' Compensation provisions o+ the
t
LaborhCode,
doomed you must comply with such provisions or this perms)
OF
DATE APPLICATION
I certify that I have read this application and state that the above informa.
Tion is correct I agree to with all city and county ordinances and
in nces and
ncomplyg cons
steno lows relating to building construction, and hereby my or
/
natives of this city to enter upon the above-mentioned property for inspection
-
pUrpasez.
(we) agree to s indemnify and keep harmless the City of Cupertino
Cgrrlen
'.PERMIT VALIDATION
against liabi liti'ess.j ts, co is and expenses which may in any way accrue
against zai¢EC i7J �p co equ nc o+ the granting p, LM1�`
SignatureofAp Iicant/Contractor Date
IN -PROCESS INSPECTION
FINAL INSPECTION
REQUIREDPRE-INSPECTION
h
INSPECTIONS
INSPECTOR DATE
INSPECTOR DATE
INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY