R-0135 r
PERMIT Rix0135
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
i 180 DAYS FROM LAST CALLED INSPECTI ON.
.� BUILDING ADDRESS �( BUILDING USE
130 / 1,9S"T 01e RESIDENTIAL COMMERCIAL OTHER
OWNER'S n (� ,/n /� // ROOF
NAME
(�_ J_ SING ll FIREAR HAZARDOUS COVERING
AREA CLASS
ADDRESS
sAMb EXISTING ROOF COVERING
-
NUMBER OF EXISTING COVERINGS /
PHONE
CONTRACTOR'S
//Y9N . TO BE REMOVED TO BE RETAINED
81914498 c0
NAME TYPE OF ROOF COVERING
ADDRESS
TY&ZlP 0000 a R19D rP16'U>rS C/Ji0i EXISTING
PHONE .�SL�/9L�3 BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER C/Q 9 03tt WOOD SHAKES x
I
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commem
ing with Section;7000) of Division 3 of the Business and Professions Code, WOOD SHINGLES
and my CIeoae is in f II Lorca end effect a/1
License Class Lic.Numbnr '/�/
Data — comragmr OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm [hat I a rpt from the Contractor's License Law for PROPOSED
the following reason. f5ec. 7031.5, Business and Professions Code: Any city
county whichrequires a permit t0 construct, alter, improve, demolish,or
repair any structure,prior to its issuance also requires theapplican[for such BUILT-UP ROOF
permit to file a Signed statement[hat he is licensed pursuant to the provisions
v 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 file basis for the alleged exemption. Any violation of Section
7031.5 by an V,applicant for a permitublects the applicant t0 a civil penalty t/
-•t ,. of not more that five hundred dollars f35oo).1: WOOD SHAKES
L] 1,a r of the properr
ty. o mV employees with wa gas as their sole
compensation wll do me work, and the structure is not intended or offered WOOD SHINGLES
for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to a of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that
such improvements a r
not intended o offered for sale. I1, however, the OTHER (SPECIFY)
buildi n9 o mprovomanl is sold within o a yaer OI completion, Ina owner
builder will have the burden Of proving that he did not build or improve for
Purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am exclusively contracting with licensed
ntractors to construct the project (Sec. 7044, Business and Professions
c
od.: The Contractor's License Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
wno builds or improves thereon;and who contracts for such projects with a
contractors)licensed pursuant m Cori ConLicense Law.
❑ I am exempt under Sec. ,B.&P.C.for this tie on FASTENER
ow Date
W ORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self insure,or a car TYPE
lift ate of We ties' Compensation Insurance,or a certified copy thereof(Sec.
3800,Lab.CO.
Policy No. Company /
❑ C find qo he It wrnished' LENGTH
1]_Carofiedc file sn tv o [ion division.
'Pplica r��v ^—�4 o FEE SUMMARY
TIFICR ATE OF EXEMPTION FROM WORKERS' p
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol-
lars($10l or less.) VALUATION
I cell TV that in the performance of the work for which this permit is
issued, shell not Compensation
any person in any manner s0 as to become subject ./� ^ —
to me Workers'ot employ
an Laws of California ft S (�
Dale Applicant
NOTICE TO–APPLICANT: If, after making this Certificate of E,umpdon, PERMIT FEE ��
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
I cellifv that 1 neve read this application and state that the above informal
correct. ag rev to comply with all city and county ordinances and
state laws relating to building construction, and hereby authorize republan / C
ta[ives of this city to enter upon the above mentioned property for inspection J
purposes.
(we) agree to s indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against liabilities,judgments,costs and expenses which may In any way accrue
against said City in consequence of the granting of this permit.
Signature of Applicant/Convector Data
Y �
.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