R-0201 PERMIT NUMBER R_ 0201
APPLICATION FOR CITY OF CUPERTINO
REROOF PERMIT INSPECTION DIVISION PERMIT E
PERMIT EXPIRES IF WORKORKIS NOT STARTED
WITHIN DAYSOF PERMIT ISSUANCE OR
180 DAYS
FROM
LLAST CALLED INSPECTION.
BUILDING ADDRESS r BUILDING USE
RESIDENTIALJL_ COMMERCIAL OTHER
OWNER'S
1- Ari A. ` HAZARDOUS ROOF
NAME , •'//L 9e FIRE COVERING
. . /_ AREA - CLASS
ADDRESS • EXISTING ROOF COVERING Stlif
NUMBER OF EXISTING COVERINGS I
PHONE
CONTRACTOR'S oo yGtm
NAME / &(—U♦� 17 � FC?0.,r � �/-/ /C„/ � TO BE REMOVED TO BE RETAINED
`7 TYPE OF ROOF COVERING
ADDRESS,
CITY &Z 7'/5 ;J__ 6� �M;5(/R-`f 90 EXISTING
. /IP
& '7 BUILT-UP ROOF
PHONE
LICENSE
ij� / / �.2� ASPHALT SHINGLES
NUMBER `� '•f' ,(�
! WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I M1eraby affirm that I am licensed under provisions of Chapter 9(commem
�i ing with Section 7000) of Division 3 of the Business and Professions code, WOOD SHINGLES
and my license is in full force and affect.
r ucameClas, _ u=.Nnmbpr�_ OTHER.(SPECIFY)
Date Contractor
WNER-BUILDER OECLARATIOp
I hes reby affirm that I am exempt from the Contractor's Licens w for PROPOSED
the following re (Sec. 7031.5, Business and Professions Code:e Any city
Hecounty whichtruc t, al ter,requires a permit to c mimprove, derprisb,or
pair any siructu e, 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 provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
• of Division 3 of the Business and Professions Code)or that he is exempt mere ASPHALT SHINGLES
m
from and e basis for the alleged exemption. Any violation of Section
7031.5 by any,applicant for a permit subjects the applicant to a civil penalty
of not more that five hundred dollars($500Lj: WOOD SHAKES
❑ I,a of the property, or my employees with wages as their sole
focompensation,will do the work, and the structure is not intended or offered WOOD SHINGLES
e sale (Sec. 7044, Business and Professions Code: The Contractor's license
Law does not apply to an owner of property who builds Or improves thereon, ✓
and who does such work himself or through his Own employees,provided that
—'
such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner' 4
builder will have the burden of proving that he did not build or improve for J
purpose of sale.). PROVIDE I.C.B.O. REPO F - NO. 79N
❑ 1, as owner of the property, am exclusively contracting with licensed
contractors-to construct the project (Sec. 7044, Business and Professions ,,��ss
Code: The Contractor's License Law does not apply to an owner of property PROVIDEMFGR. INSTALLATOI/II&Q S.
{) who bullas orrmproves thereon,and who contracts for such projects with a •, O
connactir ls)licensed pursuant to the Contractor's License Lew.
❑ 1 am exempt under Sec. e.&P.C.for this
sal On /
FASTENER
Ow Det
WORKERS'COMPENSATION DECLARATION (J
hereby affirm mat I have'a certificate of consent to self.'insure,or a TYPE 1 I/`
tificate of Workers'Compensation Insurance,ora ani fled copy thereof(Sec.
3800,Lab.C•). /fA..
Policy No. Company f\r /i\
HCerefipd copv 15 hereby fumisM1ed:7 LENGTH
Ce rt it iad copy is filed with me city Inspection division.
Applicant FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol. n 1�•�
Iles 1$100)or less.) VALUATION
1 certify that in the performance of the work for which this permit i
issued, I shall not employ any Parson in any manner s0 as to become subject
to the Workers'Compensation Laws of Califor ja/� (/ . J� el
-� Date Applicant 1 61
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption, PERMIT FEE /
•�� you should become subject to the Workers Compensation provisions 01 the
;1 Labor Code, you must forthwith comply with such provisions or this permit DATE OF APPLICATION
shall be deemed invoked.
I certify that I have read this application and state that the above informs
tion is correct. I agree to comply with all city and county eminences and /1 /
state.ltaws reletin t0 building construction, and hereby authorize repressor G 7
,.I've,OI this t +o enter upon the abovementioned property for inspection
pu rp asas.
(wo) eco se ¢¢ inaymn tv dharmmas ma r+v of Cupertino PERMIT VALIDATION
against I'pgil' .I ¢m nts,c e e which may any w v accrue
against f ns buany 0//%�gsof his Form'f.�
2 L/
Si to of Applicant/Conn for Date
REQUIRED E-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR Di INSPECTOR DATE
[NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY