R 0974 PERMIT
APPLICATION FOR CITY OFCUPERTINO NUMBERR- 0974
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMITNOT .
PERMIT 180 DA S If F PERMIT
SSUANC OR
ED
WITHIN S F DAMS OF PERMIT ISSUANCE OR
IBD DAYS FROM LAST CALLED INSPECTION.
BUILDINGADDRESSBUILDING USE
1o+11 LV _ dole,
Ave,
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUSROOF
'NAME db Gov n FIRECOVERING
AREA CLASS
ADDRESS �nl'I'I � 0y)-si a Ile, �,� XISTING ROOF COVERING
PHONE 4 "Clp NUMBER OF EXISTING COVERINGS
CONTRACTOR'S / yI
NAME_._&-r21+ AnoI—i jilki I NG TO BE REMOVED Q�� � TO BE RETAINED
ADDRESS �Qj r (' J,� TYPE OF ROOF COVERING
CITY&Zia �I"I I �I'f'9'Y l
EXISTING
S :kik sosG 95112
PHONE Lite, yflf�-'7&-A I BUILT-UP ROOF
LICENSE .� y-� tpASPHALT SHINGLES
NUMBER (/ I 0 ,1 �-��"il
WOOD SHAKES �P(1 . a Y. -5
LICENSED CONTRACTORS DECLARATION
I e.raey affirm 7000 of Division
under a Business
of Chaphe (con-hose
od., pr, g
.in. with Section T000l of omismn a m me en.;n.,s and Pralle..ionf coda, - WOOD SHINCi LES I
and my ic.n.a;v t r ce and effect 30241; '
u4.n.ec Can r. h., N[, OTHER (SPIE@IFdx5 'D
Date Contractor PP 55i6�y
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor. Licence Law for PROPOS y
he tollawing reason. (sac. ]0]1.6, Business and Professions Code: Any city �1 OF `ul'EH I INU .
or county which requires a permit tc construct, alter, improve, demolish,or
repair any structure,prior to its issuance, also reminds the eppllcml for such BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provision,
. of the Contractor'.3ofthe License Law(Chapter Profession, (commencing. a to exempt there
of Division S of ane Business end gedexmCode)or that of rept mmo- ASPHALT SHINGL
from end by an basis for 700 alleged exemption. Any violation Section
of 31,a.' rmany,,five hundred
for a Permit uel.cv[M1e applicant t0 a Civil penalty
of 0 1,as
ma[r of hundred done..($500).):em WOOD SHAKES ,V••\J
❑ I,all oWnail of the property, or he employees with wages a,(hob,oto
core (Sec. will do the work, and 100 structure od. if not .nlr. ,. ',d or offered
for se (sae.Topa, 1.a,Os and of
coda: me .Improve. hereon. WOOD SHINGLES
L--.d'---ho netdoes apply to en owner Of property his
builds to ees, ore,thereon,
suchand mp r o vent such work net elfInt or ed .1through N,own emalle. If,provided that I II
such improvememf are net Intended or offered for ,ala. n, However, the OTHER (SPECIFY) Z CDX PI
building or improvement is sold within one year of c mpletion, the owner.
builder will have the burden of proving that he did not build or improve for
purpose I of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the heProperty,project
a exclusively connecting with licensed
code: The to construct mo se Law (Sec, l0oa• to Rau and Professions property Code: The or improves thereon,
and whoeso
co[ facts foe such
pr ofocts with
a PROVIDE MFGR. INSTALLATION SPECS.
who bunds or improves [hereon, entl who actor's Li fore La projects wire a
connect am exempt
pursuant to m.Connector's License Lew.
❑ em exempt under Sec: ,B.BiP.C.for this
reason FASTENER
owner Date
WORKERS'COM PENSATION DECLARATION
to ON �bl � N�� �s
1 hereby affirm that I nava e certificate or consent m self insure,ar a car. TYPE 1`' N
of ices of Workers' Cnompensa bn ,uran or a c tified copy thereof(Sac.
Polis Lab.ti 10'R OOOSJ3�S(n ,,,,,,f
Policy No. V Company �(^�IE+�- T
--0 Certified Copy Is hereby furnished. - LENGTH
Corti l' d copy is(;led with me cit 'nepection d;vi s;on.
Applicant FEE SUMMARY
C CA M WORKERS'
CO Phe completed
the
NCE
(This,Ertl eed of be completed if[M1e permit is for one hundred dol- 5
tars 161000)o'g.) VALUATION
I certify at in the performance of the work lot which coif permit is
;,turd, I ,hell-not employ any person i any manner to a,to become subject
m the Worker:Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Cerurcaaa of Exemption, PERMIT FEE �� ISIrij
you should become subject to the Worker:Compensation provisions or me
Leber Code, you must forthwith comply with such provision.or this permit DATE Q LIGATION
,hall be deemed invoked.
I certify that I nave read this application and flet.[hat the above Informs.
tion if car tact I agree 10 comply with all city and county ordinances and s�(q �
.,ate lewe ralating [o bu lltling construction, and hereby authorize reprman- FEB 25
tativef of this city to enter upon the above-mentioned property for inspection
Par faa.
fw.l ;gra: to save indemnify and keep barrel... the City of Cupertino CIT�,�BMI,TJVIAL111DATION
na Ii it l ti ss, judg env, m entl expanwa which they in any way accrue
Rat f tl ItV in ca nu . e 9renting Of this Permit.
• Signeto
or
pplicent/Contractor Data
I tl x7y==
REOU ED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONSh INSPECTOR DATE '• INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY