R-0166 PERMIT R_ 0166
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
PERMIT EXPIRES IF WORK IS NOT STARTED
='••• WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
. .�� BUILDING ADDRESS BUILDING USE
T
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME �MI �--� �7J �0�✓� FIRE COVERING
AREA CLASS
ADDRESS 7�f/�� �Q–�� *1^�1� . • EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE —
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADDRESS,
CITY&ZIP 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(commem
ting with Section 7000) of Division 3 of the Bmines:and Professions code, WOOD SHINGLES
and my license Ie in fou force and affect.
License Class Lic.Number
Data Contractor OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm mat I am exempt from the Convact0i s License Law for PROPOSED
[M1e following reason. (Sec. 7031.5, Business and Professions Cade: Any city
or county which requires a permit to construct, alter, improve, demolisn,°r
repair any strucmra,prior to its issuance also act fres me appD<anl 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 Corte)or that he is exempt there ASPHALT SHINGLES
from end the basis for the alleged a emplioion n. Any vic of Section
J031.5 by any applicant for a permit subjects the applicant to a civil penalty
.• of not mora met five hundred dollars($500).): WOOD SHAKES (�
- ❑ I'as owner Of the property,tur my employees with wages as their sole
focompensation, will do the work,and he structure is not intended p Offered
r sale (Sec. 7044, Business and Professions code: The Contractor's License WOOD SHINGLES
Low tlOes not apply to on owner of property who builds Or improves IM1eraon,
.fid who does such work himself or through his own employees,mmided that
such improvements are net intended 0 offered for sale. If, however, the OTHER (SPECIFY)
build ng o mprovement is said within rO one year of completiOq In.Owner
builder will have[M1e burden Of proving that he did not build or Improve for
noon;Palo.).ownPROVIDE I.C.B.O. REPORT NO.
I, s owns. of me prppenv, am e.cfuzmely contracting who licensed
P actors to construct the project (Sec. 7044, Business and Press
ofions
code: The Contracto:a License Law does net apply 1.anowner ofproperty pROVIDEMFGR. INSTALLATONSPECS.
Wn° bu llds o improves thereon,eren, and who c°ntracts for such projects with a
C.ntrann sl licaned pura0artt 1.the Contractor's License Low.
❑ am a.empt under sec. ,Bra P.C.for thisreason FASTENER
Owner
Owner Dare
WORKERS'COMPENSATI NDECLARATION
1 hareby affirm that I have a certificate of consent 10 self.insure,0 TYPE
till<a%a of Workers' Comp...aline Insurance,or a Certified Copy.thereof(Sec.
3800,Lab.C,1.
Policy No. C.,e,.e
gCertified copy is hereby furnished. LENGTH.
Certified copy Is filed with the city inspection division.
App°°°°` - FEE SUMMARY
CERTIFICATE E EXEMPTION FROM WORKERS'
COMPENSATION completed
ON INSURANCE(This -
($ 0 section need not be completed if [M1e permit is for one hundred tlo1-
Iars($100)or has.i VALUATION 3.s�
I certify she that in 1be performance of ny man k for as which this permit
is issued,the mall not employ any person any manner so as to become subject I '
Di a Workers'Compensation Laws of Calitorniann
Date Applicant
you
ICEshould
ld APPLICANT: If,o after making this Compensation
p of Exrs,of a PERMIT FEE
you rM1 od become subject i the Workers'h Such provisions
ns., this a the
Labor
be diumeta da okoa forthwith comply with spcn provisions 0r his permit DATE OF APPLICATION
a I certify that I have read this application and state that the above inform,.
tion is correct. I agree to Comply with all city and count, ordinances and 4
7�41
state laws relating to building construction, and hereby authorize opener,
t°tives of this city t°enter upon the above mentioned property for inspection
purposes.
(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 [
Vagainst said City in consequence of the granting of this permit.
/ Signature of Applicant/Contractor Data
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