R-0126 PERMIT R_ O�
APPLICATION FOR CITY OF CUPERTINO NUMBER 26
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
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
e —EZ HAZARDOUS ROOF
�s�" FIRE
NAME a� �/ // �� AREA CLASS COVERING
ADDRESS ��N06—VIMn/G C4 A0r.aEXISTING ROOF COVERING
�
PHONENUMBER OF EXISTING COVERINGS
R'S
CONTRACTO
TO BE REMOVED TO BE RETAINED
NAME a"i/ .47- 17 O TYPE OF ROOF COVERING
ADDRESS, 9'sl
CITY&ZIP / � / fo Al (f S'G EXISTING
PHONE //
X411 _ Siry BUILT-UP ROOF (�
LICENSE9 7 �� 7 ASPHALT SHINGLES
d
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION -
hereby affirm that I of Division
under provisions or Chapters(common.
mg with Rection >000)force
Dimsmn a or me Business and Professions coca, WOOD SHINGLES
end mV license is in full torte and efluct.
License Class Con Number-9
Date , � UA NuInr — s OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for PROPOSED
the following r0 (Sec. 7031.5, Business and Professions Code: Any city
or county whichrequiresa Permit to Construct, alter, improve, d°molistuor
repair any structure, prior to Its issuance also requires the applicant for such BUILT-UP ROOF
mit to file a signed statement that he f
peris licensed pursuant to the provisions
Of
the Contractor's License Law (Chapter 9 (commencing with Section 7000)
OI Division 3 Of the Business and Professions Code)or m
at he is'exempt mere ASPHALT SHINGLES
from 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
M1 Of not more that five hundred dollars($500).): WOOD SHAKES
❑ 1, a ror me Property, or my employees with wages as their sole
fompensati On, wiII do the work, and the structure is not intended o offered
r safe (Sec. 7044, Business and Professions code: The Contractors License WOOD SHINGLES
Law does not apply to an Owner of property who builds Or improves thereon,
and who does such work himself or through his own employees,provided that
such improvamrnb are not intended O offered for sale. If, however, me OTHER (SPECIFY)
building ° improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or Improve for
purpose' 0Aaown PROVIDE I.C.B.O. REPORT NO.
❑ I, s Owner of the property,je a c. 70 4, connecting with licensed
} contractors Contractor's nstthe se Law (sec. t app Bto naso ane Professions
code: Ths oiprovesthereon,
and doeswho cot tracts for
a h ner projects
is with
PROVIDE MFGR. INSTALLATION SPECS.
who builds °licensed
thereon, and who contracts fore La projects wltM1 a
ontrectam lit enzetl pursuant to the Contractor's License Law.
p lam exempt untler sec. ,B.a P.e.for hisreason FASTENER
OwnerDate
WORKERS'COMPENSATION DECLARATION
I hereby a++irm met have a certificate of consent to self.insure,or scar TYPE
tificate of Workers' Compensation Insurance,Ora al, ified copy thereof(Sec,
3800,Lab.C, �1�fPa ��
Policy No. 4 Company_ -'
❑ Certifil opV Is hereby Intel . LENGTH -
❑ C¢!Ii(ietl copy Is filed with the City inspection division,
Applicant FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE _
(This se"
"firm hoed not be completed if the permit is for one hundred doh '
Tars($to0)Or lass. ) VALUATION J/
1 certify that in the performance of the work for which his permit is '
issued, I shall not employ any person in any manner to as to became subject
to h.;WW;" enApplic Laws of ma rnt�/: //
Doe Applicant ��XX rfipGesf ,
NC ICET APPLICANT: Ii, after Ing this Cagillificate of Exemption, PERMIT FEE Id.2
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 certify that I have read 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 buildingconstruction, and hereby authorize repre$en-
'alive$of this City to enter upon the above mentioned property for inspection '
purposes.
(We) agree to love, indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against liabilities,judgments,costs and expenses which may in any way accrue.
eg I st said City' consequence of 1.4 granting of this permit. -
Ignaara of
APPII rnnacror Oatff
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
F
INSPECTOR COPY