R-0219 PERMIT R_ 021 (]
APPLICATION FOR CITY OF CUPERTINO NUMBER J
INSPECTION DIVISION PERMITS
REROOF PERMIT
AJ PERMIT ES IF WORKORKIS NOT STARTED
id 180 DAYS AM$OF PERMIT ISSUANCE OR
� 180 DAYSS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
RESIDENTIAL_ COMMERCIAL OTHER
-
OWNERS
NAME '�G�r� xaa,A7 HAZARDOUS ROOF
FIRE COVERING
AREA CLASS
ADDRESS �y�/ ( .� (c EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
1 TO BE REMOVED TO BE RETAINED
f _
NAME tt�-- q� ,�,,�cam /^ TYPE OF ROOF COVERING
ADDRESS
CITY&ZIP L ✓ IYL >J/ � EXISTING
PHONE( ! 14K O ;W`9 Al221i BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
.. .:NUMBER / •— WOOD SHAKES (/
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(comment WOOD SHINGLES
ring with Section 7000) of Division 3 of he Sentinels and Professions code,
nd mr license is fu fc dna e+mct.
License lass •� Lic.Numbe�
Date _ — contractoreiiii. OTHER (SPECIFY)
OWNER-BUILDER DECLARATION /
I hereby affirm that I am exempt from the contractors License Law for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
county which s requires a permit to construct, alter, improve, demolsh,,or
or
any structure, prior to its issuance, also requires the applicant 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)
A f Division 3 of the Business and Professions Code)or that he is exempt there, ASPHALT SHINGLES -
' Tf.' from and the basis for the alleged exemption. Any violation Of Section _
7031.5 by any.adPlic ant ,ora permit subjects the applicant 10 a civil penalty
aT.r. of not more that live hundred dollars 1$5001.1: WOOD SHAKES
j ❑ I, a er of the ppery,tormey mployes their Sol.
with wages as thsolo
mpnsatmrW rowill do the 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 er of property who builds or improves thereon,
antl who does such work himself or through his own employees,provided that
uch improvements a not intended o offered for sale. It, however, the• OTHER (SPECIFY)
buil ai no 0rmmovem nt is sold within one year of compn,letiothe o n
builder will have the burden o, proving that he did not build Or impr0 efor
purpose of sale.)' I PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner o1 the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code* TheCentracier'sLicenseLawdoesnotapplytoanownerofProperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who contracts for such projects with a
ontracto r(s)licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec. ,B.&P.C.for this ason FASTENER
ow Data
Owner WORKERS'COMPENSATION DECLARATION
I hereby affirm trial I have a certificate of consent to self insure,or a at TYPE C s�fn
til)cote of IN k ompgnsafj�surori 0,a cerlified opy SM1ereo}(Sec,
3800, Lab.Cd `•arY4PY � {{ „!� ,
Policy No. Company d- 4S
L.certified copy is hereby furnished. - LENGTH j
y�CpL Celtifia cop fled r+i[II city into t/O rye' tion.
Alsplicantf( YI �yK-I��A�I/ v�
CERTIFICATE O E EMPTION'FROM WORKERS' FEE SUMMARY
COMPENSATION INSURANCE
(This section need not be completed i1 the permit is for one hundred doh `' 1
lays 1$1001 or less.) VALUA710N
I certify that in the performance o, the work for which this permit Is I —s
issued, I shall not employ any person in any manner so as t0 become subject
to the Workers'Compensation Laws of California. Na
Date Applicant
NOTICE TO APPLICANT: I,, 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 bedeamed rayoked. %' - DATE OF APPLICATION
I certify that I have read this application and state that the above lnforma _
tion is correct. I agree to comply with all city and county orainan,s and
state laws relating to building construction, and hereby authorize rep
Sen.
tatives of this city to enter upon the above-mentioned property for imp. ion
purposes.
(We) agree to s Indemnify and keep harmless the City of,Cupertino PERMIT VALIDATION
against liabilitie:,judg ta.costs ane uses which may in any way accrue
ag.;n,t(Said cit m c ounc f or ming of tM1' pormiL
signature Of KpPlicant/CooFfrTi Date
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS 1'
INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY