R-0189 PERMIT' Qpp
- APPLICATION=FOR - CITY OF CUPERT11ii --�� NUMBER R- 01 UJ'-
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
s' 1' 180 DAYS FROM LAST CALLED INSPECTION.
f
BUILDING ADDRESS BUILDING USE
t'
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
• ...�- ,C/��j/,--/j,""y.r.� HAZARDOUS ROOF
NAME FIRE COVERING
�n AREA CLASS
ADDRESS //—� /7.CXJEXISTING ROOF COVERING
�✓J
NUMBER OF EXISTING COVERINGS
PHONE
IY-!'(
c CONTRACTOR S, _ F w,...t q„ ✓
` O r/N/ jC�� + TO BE REMOVED TO BE RETAINED
NAME / 9 4 TYPE OF ROOF COVERING I
" • r
ADDRESS �J��*"j�� SLA n,/
y,,, F� CITY&ZIP � Lf 11'� ��' �� /�•�� rr EXISTING
PHONE BUILT-UP ROOF - -
•N LICENSE,,, ,z� ;,/ x, ASPHALT SHINGLES
vk
Iaxc,n. . - NUMBER s,• R �'`� WOOD SHAKES
"LICENSED CONT Q$
FIACTy^ DECLARATION
C � - 1 hereby aflir!Ntbat I am Iicemad,dFdi;r60Fsirms of Chapter 9(commen
Ing m s nsl
pp 7000) f Diyontia f the Business and Professions Code, WOOD SHINGLES
�p1 �:. • andmy R[an:e''Idell a
'I''n nd effadl..S iGjp�.v,( ..
License Class Llcu.Number -
Date Contractor OTHER (SPECIFY) -
O BUILDER DECLA ATION - ?
I hereby affirm that I am exempt from the Contractor's License Lew for PROPOSED
,he following raS (Sec. 7031.5, Business and Professions Code: Any city
or county whichrequires a permit to construct, alter, improve, dem°Iith,or
c
repair;any-structure, prior to its hsuane also requires the applicant for such BUILT-UP ROOF
perm t(to 1116 signed ste40ment that he Is licensed pursuant to the prow sons
of,th Co t actor's License Law (Cha6h D'(commenc'rg With Sect on 70001 -
c
of'Oivision 9, f the Business and.Professions Code)or th th- Is exempt there ASPHALT SHINGLES
from and the basis for the °Ilse d exemption. Any violljliorr of Section
(
7031.5 byo y pave hu fora permit subjects Lha applicant to d civil penally WOOD SHAKES
' 01 not more that fire 'he drops
dollas.... 185y em
❑ 1, ,i owner °t tM1h property, or
he employees with weeds as r offered
ifsolo
for sale ( ion 04 oo ese soak, Profess,ns structure is not intended 's Limned WOOD SHINGLES
for sales e[. 7044, Business andnen Professions who
The or improves
License
Lew does not apply o an owner of through
his
n em to ees, ores thereon,
i� and who dove such work himself or ed oro his own employees,however that
ucn iull or
pr v are nix end with n offered year
run om. eti however,owner OTHER (SPECIFY)
bus Iding o improvement is sold within one yeas of completion,or me owner
our ., will have me burden OI proving eset he air not build or improve for
°°'P°'°°"°'p') --T—+- ----T- - d- PROVI.DE_I_C,B.O..REPORT NO.
❑ I, a of he orgparty, exclusively co Vec[mg wrtM1 licensed— lwT T
contractors to construct the project (Sec 7044 Business and Profess o s '• `
CodeThe Contractor's L'crnedfLeWdoes not apply toe werofProperty - PROVIDE MFGR. INSTAL'LATIONSPECS.
who be tons o improves thereon,-and who contracts for such projects with a
pmrac[or(sl licensed pursuant to the Contractor's License Law. - -
❑ 1 am exempt under Sec. ,B.a P.C.for his FASTENER
reason
owner Data
WORKERS'COMPENSATION DECLARATION / /J
hereby affirm that I have a certificate of[ ent to self.insure,o TYPEAj
7
Lill ca te,of Wo kers,C mp°nsation Insurance,or a certified tory thereof(Sac.
3800,Lab.�i 1,,. (� �s,ws.�� ,x� • ' ap - _
Policy NoaC'r7//S O7liszb rs' rd /�K.7/�iv�N ` / / �/a / I/
Certified[ he b nisne r LENGTH 0O/��/ Y
ellif ie fila [ sped: viSiOn.
9
^ ° FEE SUMMARY
CERTIFICATEEXEMPTION OM WORKERS'
COMPENSATION INSURANCE
(This section need n0[ be completer if theepermit is Ina one hundred tl01- /-�(//j��•
lar,($10,1or leu.) - - VALUATION—t✓') y Y
certify that in the performance of any
work for which this permit is '
j iAued, I mall not employ any wins o in any mannan 50 az to become subject '--
o me Workers'Compensation on Lawsof California. _ .ra
Dat° Applicant _ --l/TsI S �/J Q•ap
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, PERMIT FEE e�IllJa� /' • r+ /
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
,hall be dsemed revoked. DATE OF APPLICATION
certify that I have rear this application and state that the above informs
tion is cornet roe roe co comply with all city and county ordinances and
st
ere laws relating to building construction, and hereby authorize rep ,,��S
resen.
f tatives of thiscity to enter upon the above mentioned property for inspection
purpose. ir` PERMIT VALIDATION
a0 t 9Tli'suss 1 d keep as whish mo City of Cupertino
yya net 1 fit us IyE9 ts,a s a d pe a which thej�w .
gr/co quer of[hag a nese'm s per� licant/Contractor Det°
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS7 INSPECTOR .. DATE b INSPECTOR 'RATE INSPECTOR DATE
i
I -NOTE: -OSHA APPROVEb ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY