R-1632 - - PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 1632
REROOF PERMIT
INSPECTION DIVISION PERMIT E
PERMIT EXPIRES IF WORKORKIS NOT STARTED N
1DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM
LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNERSHAZAOOF
,.,
NAME )0 ; ')6Ot, I1nn1CA ) f O `` Fl AREAR DOUS , d OVsi CLASS ING
ADDRESS ?_ZL1_2\7 v��-C�i'\'� ezx� EXISTING ROOF COVERING
PHONE — r,j NUMBER OF EXISTING COVERINGS L
CONTRACTOR'S TO BE REMOVED L TO BE RETAINED
NAME QPYYI Q,fn c TYPE OF ROOF COVERING
ADDRESS, IW TDA jQ\rP S�, �J �!✓r" EXIS ING
ADDRESS
Cj
PHONE(408), IS3 'IBUILT-UP ROOF
LICENSE ASPHALT SHINGLES X
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9lcommem
ing with Section 7000) of Division 3 of me Business and Professions Code, WOOD SHINGLES
and my license is in lu force and effect.
Li cense Class si� ..�g�� Lid Number
Date /9b – Contractor OTHER (SPECIFY)
OWN R DEC LA RATI ON
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
rthe following reason. (Sec. 7031.5, Business and Professions Code: Any city
county which requires a permit to Construct, altar, improve, deolisli
epairnm
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)
. pf Division 3 of the Business and Professions Code)or that he is exempt there. 'ASPHALT SHINGLES
from and the basis for the all egad exemption. Any violation of Section T'—I
7031.5 by any_applicant for a permitubjects the applicant to a civil penalty
of net more that five hundred dollars($500).): WOOD SHAKES
❑ I,as owner of the property, or my employees with wages as their sola
compensation,will do the work, and the structure is not intended or offered
for sale (Sec. 7044. Business and Profession:Coda: 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,provid.d that
imvm
such prpear a 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 PROVIDE LC.B.O. REPORT N0.
❑ I, a o1 me property, a exclusively contracting with licensee
ntractors to construct the project (Sec. 7044, Business and Professions
c
oode: The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
.no buiIds o improves thereon, and who contracts for such projects with a
contractor(s) Incensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec. ,B.&P.C.for this FASTENER
Own., Date - 1
WORKERS'COMPENSATION DECLARATION ^//
hereby affirm mat I have a certificate of consent to self.insure,o TYPE sr�'
ti licate of Worker' Compensation Insurance,or ancertified copy thereof(Sec.
3800,Lab C� ). � —l?I�o ,S?l� F_tf✓�\A
Policy ab C mpany Y-
❑ Cartibetl copy is hereby furnished. LENGTH n
❑ Corbf ie py is filen wyb tpe city action division. -
Applicant .�.'-��. 4.,./nn}V ESUMMARY
IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This socxion need not be completed if the permit is for one hundred dol C�
lar.(Serio or lea..) VALUATION ryl t .a9 On
In.,I certify at in the performance of the work for which this permit
issued, I shall not employ any person in any manner so as to become subject
to the Workers'Compensation Laws of California. LrQ/r
Dote Applicant /
NOTICE TO APPLICANT: If, after making this Certificate Of Exemption, PERMIT FEE V
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 reed this application and state that the above Informs
Pon Is correct. pg ree to comply with all city and county ordinances and
state laws relating to building construction, and hereby authorize rapresem
tatives of this city to enter upon the above mentioned propertyfor inspection
purposes.
(We) agree to a indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against liabilities, judgments,costs and expenses which may in any way accrue
oeai�5tpaid City in con aau.nce of me drantmg or this permit.
• �(j�.�J
Sigis'afure of App eCt6rill" Dee r
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS hINSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY