R-0161 1
FNIUMBERR-
RMIT 0161APPLICATION FOR CITY OF CUPERTINO o
REROOF PERMIT INSPECTION DIVISION PER MIr EXPlR4noN
PERMIT EXPIRES IF WORK IS NOT STARTED
_ WITHIN 180 DAYS OF PERMIT ISSUANCE OR
' / r - 180 DAYS FROM LAST CALLED INSPECTION.
BUILDIN�G7 ADDRESS �} BUILDING USE
/ /�' �. AV, RESIDENTI AlCOMMERCIAL OTHER
OWNERS\NAME �IL �N� �i�..//� L1�5 HAZARDOUS ROOF
FIRE . COVERING
/� AREA CLASS
/04 7 5 /�/r�" ii AU EXISTING ROOF COVERING
q �
ADDRESS /' /, I
PHONE CS�— T� �— NUMBER OF EXISTING COVERINGS 6NL ( '
CONTRACTOR'Sn
b� y_ �(�G TO BE REMOVED X TO BE RETAINED
NAME /�J L,�J ' \ TYPE OF ROOF COVERING
ADDRESS,
CITY 81 ZIP S %� ��•.J . EXISTING
�_��— —
PHONE
J 1 �5�1r�4/' BUILT-UP ROOF
LICENSE ASPHALTSHINGL S
NUMBER CI�(� J WOOD SHAKES/ k�
LmEat ED CONTRA under DECLARATION '
1 hereby affirm that am R"ensatl under prgvisigns pr chaeta.g(pommen- WOOD SH NG ES
cin6 with Section 70001 1 Division 3 of the Business d Professions Code,
and my license 1 f rce and effect (,
License �� Lic.Numb" i ��a�J
Data 5�°` `rT Cgntraptq, �CCt OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm mat 1 am exempt be, he Contractor's License Law for
S
the following reason. (Sec. 7031.5, Business and Professions Code: Any city PROPOSED
Or county Whichrequires a permit to construct, alter, improve, dem Olish,0r
epeir env :Fucmre, prior to its issuancealso requires the applicant for such BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant t0 the prOvlsi ons
'•T:r111 of the Contractor's Licansa Law (Chapter 9 (commencing with Section 7000)
of Divisiom3 of the Business and Professions code)or that he is exempt there- ASPHALT SHINGLES
Irom antl mo basis for the alleged exemption. Any violation of Section
f• 7031.5 by any applicant for a permit subjects the applicant to a civil penalty 1_
of not more that five hundred dollars($5000.): WOOD SHAKES �l
r ❑ 1,as owner of the property,or my employees with wages as their sole
compensation, will do me work. and the structure is not intended or offered WOOD SHINGLES
for sale (Sec. 7090, Business and Professions Code: The Contractor's License
Lew does not apply 10 an owner
of property who builds or improves thereon,
and who does such work M1 arse lior through his Own employees,provided that
cath improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building 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.B.O. REPORT NO.
❑ I. as
owner of me property, am exclusively contracting with licensed 1 y
contractors to construct the project (Sec. 7044, Business and Professions 5r
Code: The Contractor's License Law does not apply to an owner o+property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who contracts for such projects with a -
com actors)licensed pursuant to the Contractor's License Law.
❑ I am exempt under See. ,Bra P.C.for this FASTENER
reason
Owner Date
W ORKERS'COMPENSATION DECLARATION (//'�/
I hereby affirm that I have a certificate of consent to self name,or a car TYPE 1 -00II
tificate of Workers'Compensation Insurance,o a certified copy thereof(Sec.
3800,Lou.Cd. A
Policy No. Company (
p❑ Certffied ewv I hereby f nisnm. LENGTH
Certified Pd�,�llIn'In. t -
Applicant r•7GdF�= FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE `+ -
(This acoon need not be completed if the permit Is for one hundred not
Iars($10Di or maS.) VALUATION 3If 7
I certify that In the performance of the work for which this permit is
j 5 issued, I Shall not employ any person in any primmer so as to become subject
to the Workers'Compensation Laws of California.
Date Applicant !!//
NOTICE TO APPLICANT: It„ager making this certificate of Exemptlan, PERMIT FEE T� P--' fC v rMa� 4-Dyou should become subject to the Workers' Compensation provisions of the
'. Labor Code, you must forthwith comply with such provisions or this permit
Snell be doomed revoked. DATE OF APPLICATION
I certify that 1 have read this application and state that the above informa
,,an is c act. I agree to comply with all city and county ordinances and
state laws relating to building construction, and hereby authorize represen-
tatives of this city to enter upon the above mentioned property for inspection
purposes. '
(We) Sem so save, indain ly and keep harmless the City of Cupertino PERMIT VALIDATION
against Iia ie,juI ens e•lind expenses which y in anyway accrue
against d Ci in n e of me granting of this per alt._ _
+t
Su6n APPU4t ontractor DJCaz'e_ l/O U /�/d
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