R-0134 PERMIT R-
APPLICATION 34
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS l,, BUILDING USE
/2 ��,! RESIDENTIAL COMMERCIAL OTHER
OWNER'S _ ,
NAME 0 m h e se HAZARDOUS ROOF
FIRE COVERING
AREA CLASS
ADDRESS /`f// � � � L-r) Yt we - EXISTING ROOF COVERING -
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S �
TO BE REMOVED TO BE RETAINED
NAME %'/l ✓D � O, r/V,AG TYPE OF ROOF COVERING
CTI / 0
IYaZP / 9/,l
EXISTING
PHONE L- ��7y1i BUILT-UP ROOF
LICENSEASPHALT SHINGLES
NUMBER ,7� ��
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(cemmem
Gmg with Section 7000) of Division 3 of the Business and Professor C da, WOOD SHINGLES
and my license is in+yll forc nw HIDA.
License Class .-L:_h J Lin Number F�'n�J s
oats
Con OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
1 M1areby 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 requires a permit to construct,alter, improve,dem Olish,or
or
any st.OG,u.a, prlot to its issuance,also requires the applicant for such BUILT-UP ROOF
C Permit m file A signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
Division 3 of the Business and Professions Code)or
that he is exempt ASPHALT SHINGLES
1,0- and the basis for he alleged exemption. Any violation of Section � /
7031.5 Pro
0th.,five hu fora permit subjects the applicant to a civil Penalty V
m not mor¢lbs,,of hundred dollars($50 0).): WOOD SHAKES
❑ I,a ail Of tM1h property, °nd he employees n with wages as r orf sole
me 1. (Sec.
will do me work, Profess ons Co re is not intended ' offered
for sale Isno apply
Business and f property Code: The Convector's License WOOD SHINGLES
Lew woes net such t0 a °f property is o builds Or improves es,prow thereon,
and imIn does enM1 work not int or intended
through his own employees,provided er,M1 suce
building
improvement: e not Inre with P one
year
for Rale. If, however,oowner OTHER (SPECIFY)
builder i Ave t improvement is sold piing to a veer OI completion,buildrthe Owner
builder will have ,no burden Of proving that he did not build Or improve for
Purpose°a,ao'sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, st the property, a exclusively Business an with licensed
contractors ,°.cPnsbucl the project (Sec. )044, Business and Professions
Coda: TheContractor's License Law does not apply to an owner o(Property PROVIDE MFGR. INSTALLATION SPECS.
who In Id or mproves thereon, and who contracts for such projects with a
contractor(s)licensed pursuant to the Contractor's I-Annse Law.
❑ 1 .m exempt under Sri. ,B.&P.C.for his
exon FASTENER
Owner Date
WORKERS'COMPENSATION DECLARATION
Ihereby affirm that I have a certificate of consent to selfinsure,or a cer
tlfl . TYPE /y/r
ca to of Workers' Compensation Insurance, c certified copy thereof(Se
3800 Lab.C.I.
Palmy No. Company
Certified copy' hereby furnished-. I LENGTH ` 1
Certitl d G}tpV til wimLrtie cit4li nsjtection division.
APPlica nt C �G A FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION NSURANCE
(This section need no, be completed if ,he permit is for one hundred dol
(0
lers(800 er Iass.) VALUATION
I certify that in the performance of the work for which this permit Is
issued, I shall not.,Ploy any person in y Prome, In as t In v sy nlac,
in the WOr ere' mpensanion Laws of CaJ+'fnrnia
oats Applicant (� .yX/%/ x LF
NOTICE TTO KI�ANT: If, atter making this Certificate of Exemption, 'a
you should become subject to the Workers'Compensation provisions of the PERM4T FEE
Labor Code, you mus, forthwith comply with such provisions or this permit 'r
shall be deemed revoked, DATE OF APP L I CATI T
I certify that 1 have read this application and state that the above informs y
stat is laws
relining
agree to comply with all city and county ordinances and p/���
state sews relating to building construction, and hereby pr authorize
erty fora inspection
U
talipes of this city to anter upon the above mentioned property for inspection
Purpose'
.
(We) agree ro save, indemnify and keep es which
ma ci,v of ayPenmo PERMIT VALIDATION
against liabilities,ci con encs,costs and expenses whim may in any waw accrue
-
against d tY con a of, granting of this palm t.
�� �� /`,�� /��� t F�5 �s/dry
Sign ature`OT APPA cant/Con for De[v I.
t 4
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR t DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY