R-0178 i
[EIMBERRRMIT O�� �V
APPLICATION FOR CITY OF CUPERTINO v
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
WITHIN PERMIT 180 DAYSOFIF PERMIT RK IS I SSTARED
SUANCETOR
s 180 DAYS FROM LAST CALLED INSPECTION,
�.' BUILDING ADDRESS BUILDING USE `
`1 n RESIDENTIALZ COMMERCIAL OTHER III
OWNI' II
HAZARDOUS ROOF
�r NAME FIRE COVERING
AREA CLASS
' ADDRESS J y
EXISTING ROOF COVERING
PHONE I�,J VQv NUMBER OF EXISTING COVERINGSK
CONTRACTOR'S
�1f�P7 1 1 A I W{/� 0O TO BE REMOVED TO BE RETAINED
NAME�'\r`S> 1`�T\11.��'J„111����....XXX�JJP ��10.7 �� \'' G TYPE OF ROOF COVERING ,.
ADDRESS.7�,� {^-p0����\ V\ 1 ` �' I` V/
CITY&(/ZIPwC� EXISTING
PHONE 41"S) 3Z1� O } BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER J_` �GP1 f0
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I of licensee 3 of t provisions of Chapter Professions
s Pomade
ai d with Section 70001 of Division 3 of the Business and Prof essmns epee, WOOD SHINGLES
ne my Casslicense is in Lull force ane affect.
License Class Lic.Number-
Do
umber
woe Contractor OTHER (SPECIFY)
Oat I m exempt
f om the RATION j
hereby lowin real that . exempt tom the Contractor's License Law for PROPOSED
or fumy allowing reason. (Sec. perri, Business and Professions Code: Any city
re county which requires a pts iss t0 construct,, alsorereqaltuires
improve, demol.such
rape°any snp<mrn, prior m its ieauanee also e hue that to thentfor.pen BUILT-UP ROOF
permit la fun a signed statemenLicense
Law inat he r licensed(commencing
pursuant it S. ilev70ons 00)
of he Connector's License Lew (Chapter s (commencing wi to Section there
from
Division 3 of basis
Business and Professions Conal or that he is exempt mare ASPHALT SHINGLES
j/ from antl the basis for the alleged rmi exemption. Any violation of Section
a ]�7 of7031.01 by any applicant fora permit subjects the applicant to a civil Penalty
pi not mora mat nae thehundred erten(48y em WOOD SHAKES
❑ I, ti Owner Of ma property, o he employees nwith wages as r air sole
r plp fS en,will en the work, Professions
structure is not intended 's Offeree
for said Isno apps Business and at
code: The Contractor'sLicenseWOOD SHINGLES'
Lew who
not apply o a owner of property his
builds to improves provided
that
and who dada en work not int or intended
r offered M1is own employees,however tnet
pen imPor improv are not and with nr eyfor sarin. If, however, m` OTHER (SPECIFY)
building or improvement bur is sold proving
one year of of buil dory me owner.
but will neva the burden of proving mat he tlitl not build or improve for
purpose
Oe sp1o.)' PROVIDE I.C.B.O. REPORT NO.
[3I, s owner Of the property, am exclusively contracting with licensee
contractors t° consumed Ibe project (Sec. 7844, Business and Professions
Cad : TheContractor's Lie enseLaw eper not net,V10an.-nor of property =pROVIDEMFGR. INSTALLATIbNSPECS.
wheedle
ilds Or improves thereon, and who Contracts for such projects with a
oniractili licensed pursuant to the Contractor's License Law.
❑ 1 am °.°rept under sea. ,B.&P,C.for hisreason FASTENER
Owner Dem
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self insure,or a ear. TYPE
tifiaam of Workers' Compensation insurance,or a certified copy thereof(Sec.
3800, b.C,1.
vol any.
J9)1
°r LENGTH
me City inspection division.p11Cen' FEE SUMMARY
�TION FROMWORKERS' O(�PENSATI NINSUPANCE
IThls sanot be compldtea if me permit is for one rundretl cut �j�j� ✓/ ^ ��
tans($ oo)or res.) VALUATION
certify that in the performance of.the work for which ones permit is
issued, I shall not employ any person in any manner so as to became subject
to ono Workers Compensation Laws of California. G, h
Date Applicant
NOTICE TO APPLICANT: If, she,
making this Certificate of Exemption, PERMIT FEE
You should become subject to the Workers'Compensation provisions of he
Labor Code,you must forthwith comply with such provisions or this permit
she I be veem.d revoked. DATE OF APPLICATIONy
is corn that have read this application and state that the above informed
stat is correct Pagree to comply with all city and county ordinances anew antl
state laws relating to enter
building construction, and hereby early fora repreeae,
talipes of this city to enter upon[M1d abovemenli n property for inspection
purposes.
(we, agf ro in mtlemnuv and keep ear less m° cur O+ Cupertino PERMIT VALIDATION
est fab'Hies, agmenti,costa and expenses ice may in any way accrue
ae Ins ie n eppen<e of the granting Of his pnrmiy,
lu
'.•. / igna P iceno/ ntrector ` Date rL n if
REO &E RE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECT NS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION.
INSPECTOR COPY