R-0215 PERMIT R_ 0215
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPMATION
REROOF PERMIT
PERMIT EXPIR FS I r WORK IS NOT STARTED
yam: WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
•.' BUILDING ADDRESS /J BUILDING USE
�V
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME FIRE COVERING
AREA CLASS
ADDRESS 7 �� EXISTING ROOF COVERING
PHONE '� �J� NUMBER OF EXISTING COVERINGS
CONTR TOR'S B
n 7 TO BE REMOVED (/ TO BE RETAINED
NAME a..R_— TYPE OF ROOF COVERING
�^ 5"aA.ir.�/yY C _
CIITYRES& ZIP J t A e - r EXISTING
PHONE BUILT-UP ROOF
LICENSE / ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(common j
aing with SICOOP 7aao) of Division 3 of the Business and Professions code, WOOD SHINGLES
nd my license is in full force and effect
License Class Lie.Number OTHER (SPECIFY)
Det. Contractor
OWNER-BUILDER DECLARATION
I hereby affirm that l am exempt from the Contractors License Law for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
or county which requires a permit to c nstruct, alter, improve, eemolish,or
repair any stmcture,prior to its issuance,elso requires the applicenNorsuch BUILT-UP ROOF
permit t0 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
A TY� from and the basis for the alleged exemption. Any violation of Section
1 f 7031.5 by any applicant fore permit subjects the applicant to a civil penalty
;•.' of not more that five hundred dollars(9500).h WOOD SHAKES j
C] I,as Owner Of the property, or my employees with wages as Thair sole
fmp.ns.tion,will do the work, and the structure is not intended of offeree WOOD SHINGLES
or 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 her
such improvements are not intended o offered for sale. If, however, the OTHER (SPECIFY)
ti ulling or 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
purpose of sale.). PROVIDE LC.g.O. REPORT N0.
D1, as owner of the property, am exclusively contracting with licensed
ontrili 1. ctruct the n,.,act S.C. 7044, Business and Professions
cns
oda: TheContraptorsLicense.Lawdoesnotapplytoanownerofpropertv
PROVIDE MFGR. INSTALLATION SPECS.
who builds or mprpves thereon, and who contracts for such projects with a
contractor(s)licensed pursuant to the Contractor's License Law.
O 1 am exempt under Sec. ,B.&P.C.far this
.a.n FASTENER y,
owner Data
WORKERS'COMPENSATION DECLARATION /
hereby affirm that I have a certificate of coo sent to self-insinsure,or can /x�! 5 1 1
till cafe a Workers' Compensation Insurance,or a certified copy thereof(Sec. TYPE
3800, Lab.Cd,
Policy No. Company
Certified Copy is hereby furnished. LENGTH
Cort it led 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 for one hundred dol 'rj
lots($100).r lass.) VALUATION 3 a
I coni+, the, In the performance of The work for which this permit is
issued n
, 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: If, after making this Certificate of Exemption, 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 rev.k.d. DATE OF APPLICATION
I certify that 1 have reed this application and state that the above informs.
tion is correct I agree to comply with all city and county ordinances and
state laws relating to building construction, and hereby authorize repres.m
_Ptives of this city to enter upon the above-mentioned property for inspection
purposes
(We) agree 1. 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 gran'ing of this permit., _
•,.:' Signature of Applicant/Contractor Date
REQUIRED PRE-INSPECTION / IN-PROCESS I NSPECTION FINAL INSPECTION
INSPECTIONSEl �
' INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY