R-0143 PERMIT Op
APPLICATION FOR CITY OF CUPERTINO NUMBER Res14
REROOF PERMIT INSPECTION DIVISION PERMITEXPIRATION
NN
PERMIT EXPIRES MI IF WOOIS
RK NOT STARTED
M1 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS JJ BUILDING USE
7S 19 0 RESIDENTIAL COMMERCIAL OTHER
�! OWNER'S
/ r /� HAZARDOUS ROOF
T NAME IS44"/ a L ��-/ ,p / AREA CFIRE OCOVERING
LASS
ADDRESS d /• L• p �,ri EXISTING ROOF COVERING
l /
7�- PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S / // F
/YAR Tinaiv TO BE REMOVED TO BE RETAINED
� NAME TTM I'�c�n�Nm TYPE OF ROOF COVERING
ADDRESSr
'CITY&ZIP IAPY!J�<' /1 ,A(/ 1x!5a1l11Zl . EXISTING
PHONE PS 7' 030x'/ BUILT-UP ROOF
LICENSEASPHALT SHINGLES
NUMBER So3 WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
hereby affirm 7000 I of licensee under provisions of Chapter s(nommen$- I
ting wim section T000) + Division a of me Bprmasr and Professions rose, WOOD SHINGLES
and my urenre it f e apart.
License_ as. " Liee Number �`
` Date convector 'ss'fal OTHER (SPECIFY)
OWNER-BUILDER DECL TION
hereby reason.
that . exempt31.5, from the ontfessios License Lew for PROPOSED the
following ich req (sec. permit Business and Professions code: Any city
re air my which requires a permit 7°construct,, alsoralter, improve, derant for
repair any file
a sign, prior statement rte ithat h ei also eyed pus Chet tol inant for rpnn BUILT-UP ROOF
permit m file tzr's Li ensthather licensed pursuanttothetion7 00)
k?>w of the Contractor's of the License Law (Chapters Code)o that a is Section>0001
fro-
Division a Lt me Business and alleged
Professions tion. or that he is exempt there ASPHALT SHINGLES
from end an basis for he allermi exemption. Any violation of Section 'I
7001.5 by any_,five hu for o Permit subjects the applicant to a civil penalty
of not mere mat rya the pre erty, ($sea).): WOOD SHAKES M�
;❑ I,a of me property,a o he employees with wanes as their sole
nompense0o�04 do me work, Professions
corn is not intended 's License WOOD SHINGLES
to w do(Sec J apply
Business andnen Professions CLC¢ The Contractor's License
Law woes not apply o an owner of property his
buries to improves thereon,
and who does ant work not int or ed through offered nir own employees,providedvetl mat
van ng or impros a His threnwew o eyfor rale. ti however,owner
OTHER (SPECIFY)
building il improvement is sola within one year of completion,or me
purpose
will neve me burden of Proving that he aid not Huila or improvefor
°prp0:1, as own PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner st me pe project
a id. 7 44,vely Business a with licensed
contractors to construct the project (Sec. t app Business and Professions
Code: The or improve'$ License and doeswho not apply m an owner
projects
is with
PROVIDE MFGR. INSTALLATION SPECS.
.no builds o arced pursuant
thereon, and who contracts fore La pr°jec6 wim a
contractor(s)liensetl oder Ont to my Contractor's License Law.
❑ am exempt under ser. ,B.a P.c.for this icer on FASTENER
ow Date
W ORKERS'COMPENSATION DECLARATION )
I hereby arrrm that I have a certificate of consent m sell insure,or a car. TYPE 5-/,B ✓1L O 5
ti+iv0te of Workers' Compensation Insurance,or a certified copy thereof(Sac. I�
3800,Lab.C.).
Policy No. Company - -
8 Certi+iaa app,is neraby furnished. iv LENGTH
Cerci+iad Copy is filed with the city inspection di si0n
Applicant FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This Sec Kon need not be completed it the Permit is for one hundred doh �D 1
A"($1 oo)or 1ers.) VALUATION (•,//
certify that in the Performance f the work for which this permit is Y
pea, I shall not employ any person any man °as t ba m subject
in ono Werke Cort�pEnzation LowzIH°rnia. —// yCp
Oats -R �/— ) APPli cant (/.L.11M9 /V
NOTICE TO APPLICANT: If, � K this Certificate o+ Exemption, PERMIT FEE r T
you should become subject to vM1{/worke 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 read this application and state that the above in+orma
tion isect. I agree m comply with all city and county ordinances and /�
state laws relating to building construction, and hereby authorize represen-
tatives
of this city to enter upon the above mentioned Property for inspection
purposes.
(we) agree to r indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against liabilities,judgments,costs and expenses which may in any way accrue MAR A. ly V
St said City in C rr ev a the greeting of mis permit. r, I
argrand, Applicant/Contractor Date
EQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY