R 1973 PERMIT
APPLICATION FOR CITY OF CUPERTINONUMBER R- 1973
REROOF PERMIT 'INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
' WITHIN S F OM OF PERMIT ISSUANCE OR
180 DAYS FROM LAST PERMIT
CALLEDI INSPECTION,
BUILDING ADDRESS BUILDING USE
10573 Randy Lane
Cupertino, CA 95014 RESIDENTIAL X— COMMERCIAL OTHER
OWNER'S
Albert G. & Theresa Re Nolan HAZARDOUS ROOF
NAME FIRE COVERING
AREA CLASS
ADDRESS 10573 Randy Lane, Cupertino, CA 95014 1 EXISTING ROOF COVERING
PHONE (408) 257-6924 N MBER OF EXISTING COVERINGS 4
CONTRACTOR'S
E REMOVED X TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADDRESS,
CITY&ZIP
rOOD
PHONE PROOF
LICENSE TSHINGLESNUMBERHAKES
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provision of Chapter 9(commem
cin, with Section 7000) of Division 3 of the Business and Prof.uinss Cod., - WOOD SHINGLES
end my lice..i.in full force and effect.
License cell 11c.Number
C.ntf.C,.r-
OTHER (SPECIFY)
Date
OWNERBUILDERDECLARATION
I hereby affirm that I am exempt from one Contractor's License Law for PROPOSED
the following reason. (Sec. 7031.5, Bniness and Professions Code: Any city
. county which requires a permit to construct,altar,improve,demolish,or
pir any structure, prior to its issuance: ei.. requires the apps `Pt for such BUILT-UP ROOF.
permit to file a signal statement that he Is licensed pursuant to the proolsi ons
Of the Contractor, License Law (Chapter 9 (commencing with Section 70001
® of Division 3 of the Business end Profession Code)or that he Is exempt there X
m
traand the basis for me staged exemption. Any violation of Section ASPHALT SHINGLES
7031.5 by any applicant for a permitubjects the applicant to a civil'ponalty
of not more that five hundred dollars(8500).1: WOOD SHAKES
'g 1, as owner of he property,or my employ...with we,..as their sola
compensation, will do the work, and the structure is not intended or offered .
for sale (Sac. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
Law does not apply to an owner of property who build.or-Improves thereon,
and who does such work himself or through his own employees,provided that
such improvements ansa not intended .roffered for sale, lf,.however, the OTHER (SPECIFY)
r
building o 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 '
purposeoe sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, s owner of the property,a .elusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply toanowner ofproperty pROVIDEMFGR. INSTALLATIONSPECS.
who builds or improves thereon, and who contracts for such projects with e
ontroctor(s)licensed pursuant to the Contractor's License Law.
❑ 1 am ...-Pt ..dal Sec. ,B.BR.C.for this FASTENER
"ower Dow
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self insure,or a car. TYPE
tiflcate of Workers' Compensation Insurance,or a certified copy thereof(Sec.
3800, Lab.Cd. -
Pollcy No. Company
® Certified copy is hereby furnished. LENGTH
Certified copy is filed with the city inspection division.
Applicant FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE QO
(This section.ne.J not be completed if the parmk Is i.r ono hundred doh Q QQ
lars($100)or less.) VALUATION
I certify that in the performance of the work for which this permit is
issued, I shall not employ any parson in any manner s0 a.to become subject ,
to the Workers'Compensation Laws of California.
Date Applicant '
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, PERMIT FEES
you should become subject t. the Workers' Compensation provisions of the
Labor Code,you must forthwith'comply with such provisions or this permit
.hall be deemed revoked. DATE OF APPLICATION
I i scNy cher I have read this comply
with al and stere the the above intenoes and
Von is laws
rect.hitt agree to ng con ruin an sty one byunty aur ordinances re r end
fate laws relating to building theaboven, and hereby aerty fora sp ctom
tomes'. mls city to enter upon the above mentions property for impaction
pur(We)
nstl egret to save, indemnify and keep harmless which me cry of Cupertino PERMIT VALIDATION
against liabilities,judgments,costs and expenses which they in any way accrue ,
eB si.aid C ty n consequence ofy granting of Cate `'
t.
CGCd�2T�, 99nfa>7i rz /[}(�
Signature of Applicant/Contractor • Data
REQUIRED PRE-INSPECTI ON IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
l OFFICE COPY