R 0895 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Rea 0895
INSPECTION DIVISION P ERMIT EXPIRATION
REROOF PERMIT PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
-- - BUILDING ADDRE a , 0 BUILDING USE
_ RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
_. NAME .Il._C,Jr lLY 1 X11 FIRE COVERING
a2 ,f �c—��L] AREA CLASS
ADDRESS VPre
'St(ll r• ` - -� _C5.3�? EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ——[,
NAME CO lir RQCfi et TO BE REMOVED - TO BE RETAINED
TYPE OF ROOF COVERING
ADDRESS, �,�r, P—h -
CITY&ZI[P �"!,-7— L ISTING
PHONE t7L—�J tiZnL- Ca Z�� BUILT-UP ROOF
LICENSE • .b ASPHALT SHINGLES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby i that I am licensed under provisions aI Chapter 9(commons
ting with Sac tion 7000) of Division 3 of the Business and Professions Cade. WOOD SHINGLES
and my license Is 1V 1 and effect.
License c Llp.Npmb.Contractor
Data OTHER (SPECIFY)
'7
OWNER-BUILDER DECLARATION
I hereby affirm that am exempt from the Contractor's License Law for PROPOSED
the following rae . (Sec.9031.5, Business and Professions Cade: Any city
or county whichrequires a permit to construct,alter.Improve, demolisn,or
repair 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 provislons
of the Contractors License Law (Chapter 9 (commencing with Section 70001
of Division 3 of the Business and Professions Code)or that he I,exempt there. ASPHALT SHINGLES '
from and the basis for the alleged exemption. Any violation of Section
l / 9031.5 by any,epplicent for a permit subject. the applicant to a civil penalty
✓ of not move 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 stmctum Is not intended or offered WOOD SHINGLES
- for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of property who builds or Improves theroan,
and who does such work himself or through his own employees,provided that
such Imvrovemgnte are not Intended or offered for sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within one veer of completion, the ownan
builder will have the burden of proving that he did not build or improve for
P......of sale.). PROVIDE I.C.B.O. REPORT NO.
El I, as owner of the property, am exclusively contracting with licensed
contract.,, 1. construct the project (Sec. 7044, Business and Professions
,.it.: Th.Contractor's License Law does no'apply 10 an owner of property PROVIDE..MFGR. INSTALLATIONSPECS.
who builtls'o mpmves Noreen, and who con Vectl for such prajacle with e
omracmr(d licensed pu must[t. he Contractor'.License Law.
❑ l am .x mm under Sae. ,B.&P.C.for his
reason FASTENER
owner Date f V
�v>
190fl KERS'COM P ENSATION DECLARATION
1 hereby.mens Nat have.n Insurance,are em ie scop Cher o q(See'. TYPE
3BOOte.f W.Kers' Compensation Insurance,o certified copy thereof(Sec.
3800,Lab C'
Policy NO. 514eby furnTsai. �, •', ��oO
Cl caaln4d copy I.hereby furnished, LENGTH
Cenif pY� filed wins the city impaction division.
AppLcant. / `. �.EX aei FEE SUMMARY<,,"
E I ATATE EXEMPTIONFROM WORKERS' Vs
COMPENSATION N S URANOE t} y/O�
(This section need not be completed if the permit is for one hundred dol- 9jx rle`/a
lar,19100)or loss.) VALUATION q sir
-(.certify that in the performance of the work for which this permit is
issued. 1 shall not employ any ptoel
erson r;WI ao as to become aubiect
N [rt'ElE rx9fa PILICANTlon Lewsy�9raing/9I^L JM
on
Applicant t/� Y//moi
NOTICE Ta APPLICANT: If, Biter m I'll W—nflceie of Exemption, PER FEE CLKI
you should become subject to the Workers Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this came,
hall be deemed rev.k.d. DATE OF APPLICATION
I certify that I have read this application and state that the above informs
tion is correct. 1 agree to comply with all city and county ordinances and JJ
state laws relating to building construction, and hereby authorize represent J
'olives of this city to enter upon the above-mentioned property for inspection
purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
p IIt Iiebilillet.judgments,costs and expenses which may In any way accrue
bill in consequence of the granting of this permit, of
Slignateoir 4,,rL1i_csnt/Vnnactdr Dao
REQUIRED PRE-IN E IO//NG � IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY