R-0244PERMIT R_ 02 A A
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APPLICA1 ION FOR CITY OF CUPERTINO NUMBER
,INSPECTION DIVISION PERMIT EXPIRATION
REROOPERMIT EXPIRES IF WORK IS NOT STARTED
F PERMIT
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
•"' -
i 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS,
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'.- - � BUILDING USE,
I
,
vOTHER"
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RESIDENTIAL - COMMERCIAL
OWNER'S a`.:.. '_ ..• ,; .,:�•
_:. ...,: ^- ..
HAZARDOUS ROOF
t
NAME NAVk—
FIRE COVERING
AREA CLASS
"
EXISTING ROOF COVERING
i !�
ADORE SSS i� C )e G. Z. ,i Q e
NUMBER OF EXISTING COVERINGS
PHONE`
CONTRACTOR'S -
t
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
NAME��i R IQpU
3Tr`C?.
"AR SS•a,. '
"C77i''&ZI(' �s"G�T'�YY-'� c �, .
_.-.-p.`.--r'x;,M-.+..«+y-.-r`-i.••-w.+,n.•
^"EXISTING^"^•"'t..^"'°.'.'s'"^"•"� '
V1e��
IR(O
e
BUILT-UP ROOF
PHONI LA 1S`
ASPHALT SHINGLES
LICENSE
NUMBER
WOOD SHAKES
+ • - LICENSED CONTRACTORS DECLARATION
the'
hereby with )of licenses under provisions oaChapterskommem
;< dna wile sett3on T000) of Division 3 of the Business and Professions coos, -
WOOD SHINGLES �t7 • ��\ .t,C �-P..��
-
a my I' a sf is rull i doff t
bicans Cla p� ,,� L Number
r
d Date InI n Contractor 1`1oc,-yn5, r.lo
OTHER (SPECIFY) • -'
' OWNER.BUILDEFiyDECLARATION°" "
"a'.'
' I hereby aff that I am exempt from he Contractor r-LicenseLaw!0
. -the fo11menh, arson.. Sri 7031.5,e8us mess antl Profess ons Cotl A y I,,-�
PROPOSED-+�--�-•- - - .-r'�•-
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in county which requires a permit to construct, alter, improve, demolish,or i'.'
-
p r mystructure, prior o is Issuance, al'so requires the appitcant for such,
9 p to PI that p licensed pursuant isio
BUILT-UP ROOFa
ed statement i[n p r
p k ti the Co t ct isLi ease Le(Chapter 9,0commencing with Set
-
f Division 3 of the Business and Professions Code) or that he is exempt Order
ASPHALT SHINGLES in
- 1 om..e d toe basis for the alleged exemption. Amr,Xvic,firdicup of Section
.7031.5 by y applicant for a perm { slbl7icts the poi t to a civ Inenalty
..
of not more mat five hundred dollars ($500)1 w` t
WOOD SHAKES
I, as owner of IM1e property, or my employees with ages as [M1vir sole
_
" mpen[atill will do the Work, and thestructure is not intended or offered
• t
for sale (Sec. 7044, Business and Professions code: The Contractors License'
WOOD'SHINGLES
Low does not apply to an owner of properly 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 oyfsw.ear. f tamaletion, the owner"
s. a"•b`ulldePCiOspagappe?burtlen of provi tt1 e p t build or improve for
pmposa:or sale) zi'u V /
..x;^' I, se 62ide: o'i"ma nroperl •a'Y, ex We1v Il
- F } Y4o nness an with licensed
PROVIDE LC.B.O. REPORT N0.
tr
y�Y4pntra[tOriato(ooni[✓uct the pmjacis(Bee.+%'1004, Business and Professions
s
. Codru"Th C t cLgrsLicense�'uwd snotapply.tq owner ofproperty
PROVIDE MFGR. INSTALLATION SPECS.
no b Id tm'PTeves thereon, Pd no toga ct fo h projects w th a
x'c t cto (s)l' edspu rau ant to a)C t}� [p n Lee.
rasogq m p oder Boc as B.&P.0 tar ah s
�.eason `�'+'"' w +s
FASTENER -
.. 101i
WORKERS'COMPENSATION-DECLARATION',
' • [` '
hereby affirm mai I have A co tircply of EomeM to self. insure, o $g +
"`TYPE
nficeto of Workers' Compenselion Insurance, or a certified copy thereof Se
'
3800, Lab T
Pole, Novi#xa P'iii l(1fl
;�Tj
eBomPenY.]J�E1L
ce .h U coov w r br fa. b dd.
LENGTH
•Q"Cerl ,fi copy filed with tie city spe<Sion division.
Applicant7jec. . c,�lo 1•t�.'.n'aA i i'0.ca
'CERTIFICATE
FEE SUMMARY
OF EXEMPTION FR® WORKERS'
COMPENSATION INSURANCE
(This section need oat be completed'ifthe permit is for one hundred dol-
�.%
lays($100)orlas1.1
VALUATION u17�7r
I terrify In atin the performance, of, the work for which this permit is
issued, I shoji not employ any person tri any. man r er so as to has me su bj oc[
to the Workers Compensation Laws 01 California.
Dote Applicant
NOTICE TO APPLICANT. I1, after making this Certificate of Exampdon.
O
PERMIT FEE
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit /
shall be seam ad revoked. .. s
D AtZ OF APPLICATION
1 certify that I have read this application and state that the above informs
"'�.�„�
tion is correct. 1 agree to comply with .all city and county ordinances and
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`•C_y
state IewiSrelating to building construction, and hereby authorize represem,
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ta[wei Of Ih1s city to enter upon the above mentioned property for inspection
1r•�
purposes.
• , (We) agree to save, indemnify and keep harmless the City of CuperBoo .
PERMIT VALIDATION
against liabilities, judgments, costs and expenses which may in any way accrue
-:eg01m0 said City in consequence of the granting of this permit.
(O
' i•Signature of Applicant/Con va. wr ,Data
PRE-INSPECTION
IN-PROCESS INSPECTION
FINAL INSPECTION
REQUIRED
INSPECTIONS
INSPECTOR DATE
INSPECTOR DATE
INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY