R-0131 s.. .. E
PERMIT R_ 0131
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITH IN 180 DAYS OF 1. PERMIT ISSUANCE
180 DAYS FROM LAST CALLEDINSPECTION.
' - BUILDING ADDRESS BUILDING USE
/ y �, v/
" /� /0- XL�y� RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME 1121 6,l ii I'l,i iG FIRE COVERING
AREA CLASS
r7C - EXISTING ROOF COVERING
ADDRESS !!JJC
PHONE. O(-S 7 NUMBER OF EXISTING COVERINGS
CONTRACTO
p,,
��- TO BE REMOVED TO BE RETAINED
NAME 6f� TYPE OF ROOF COVERING
ADDRES
CITY&ZSP /7UiJY� /�r -�- EXISTING.,.,,-""`
PHONE �O®'7>Z-OU0`3 BUILT-UP ROOF
LICENSE •l/J'7%�/ ASPHALT SHINGLES
NUMBER /J
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter g(commen- WOOD SHINGLES
ting with Sectio 70001 of Division 3 of the Business and Professions Code,
and my license is n fuDsforce and effect /f
License Clas � Ty Lic.Number yr 99
Date DECLARATION
R OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
hereby affirm that . exempt from the Contractor's License Law for PROPOSED
one following reason. (Sec. permit Business and Professions Code: Any city \ /
re air any strum requires a permit to construct,re alter, improve, dem Ohsuch X
repair any file
a sign prion a its issuance,eei also requires Netapplicant hp fol ruin BUILT-UP ROOF
01 tha t fl Li statement that M1 om pursuant it the provisions
., 01 th Contractor'se License Law ro pt 9 (commencing g res exempt
on 7000)
there
t of D 3 f the Business thand Professions tion. that of Is exempt there as
+ ` tram d ah rb fir for the alleged ptt Any - lotion of Section
ASPHALT SHINGLES
�•, of not e y applicant for a permit subjects the t0 a civ penalty
of not mire that rye the pro dollars($500).):my em WOOD SHAKES
- I] I,a of the property, ° he employees with wages as roffsole
mpee (Seen wire de ess work, Profess nsCostructure it net ontr cto 's License WOOD SHINGLES
fpr sale (Sec 7 apply
Business andProfessionsCode: The Contractor's License
Law who
net apply [O an owner Or through
his
builds of Improves theprovided
that -
!• and with does such work not int or throw gn his own emale. If,provided that
such ng or improv are not old wee or,offered year
fof sale. If, however, theOTHER (SPECIFY)
builder Or improvement t e bur sold roving one year of complof build
p
builder will have the burden of proving that he did not build orimprove nfor
our prise of sown PROVIDE I.C.B.O. REPORT NO.
I, as to o st the property, a exclusively cosiness an Pr licensed
contractors to construct the project (Bet.not
Business nesr and Professions
Code: TM1s or improves
License
on,and doeswho cot appts to an such
pr acts with
PROVIDE MFGR. INSTALLATION SPECS.
who ac ions 'ensed pursuant
thereon, and ons contracts for rum projects vies a
contractors)licensed n er Se to the Contractor's License Law.
I
❑ roes exempt under ser. ,e.aP.c.mr n,ir FASTENER
reason
Owner Date -
.WORKERS'COMPENSATION DEC sent to ON
he of orklm that Compenhavisation
certificateurnof concent n scram:pre,.,.car TYPE
oiticate of Workers' Compensation Insurance,or a gertifietl copy thereof(Sec
3800, Lab. �.y/,,,. / C / y �•�f /J ��b L / y� 1
PLbcy NL.-�' -�Company J/ (.(/ /- �/✓.J'/�f//l/
Ceafilied copy is hereby furnished. LENGTH
C:rb red c y is filed.with N 'oy' p tion elvision.
App1cant �� ���e FEE SUMMARY
CER IFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE - /-
(This section need not be completed if the permit is for one hundred Loh
r. e
]ars($100)or lesi VALUATION
I certify that in the performance of the work for which this permit Is
issued, I shall not employ any person In any manner so as to became subject �yV
to he Workers'Compensation Laws of California.
Oats Applicant I
NOTICE TO APPLICANT: H, after making this Cenlfmars of Exemption, PERMIT FEE
you should become subject to the Workerscompensation provisions of the
Labor Code, you must forthwith comply with such provisions or ibis permit
shall be deemed revoked. DATE IF APP ICA����TION
certify that 1 have read this application and state that the above noes and I V kv�s—
Ron c correct I agree t0 comply with all city and county ordinances and
state laws relating to building construction, and hereby autnori£e rorrom
tatives of this city to enter upon the above mentioned propeliy.tgy,I,,3 action
purpose' ` y P P RMIT VALIDATION -
(We) agree oro save,indemnify and keep M1armlers ese Clty of Cupertino
against liabilities, judgments,.costs and expenseswhich may In any way accrue
A+:. . against Asaid City in consequence of the granting of this permit.
Sign fur ofApplicant/Contractor �Ostia
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTIO. FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR - DATE INSPECTOR DATE_
NOTE: ' OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY