R-0268;A4
INSPECTOR COPY
PERMIT R_ O�CO
APPLICATION FOR CITY OF CUPERTINO NUMBER vQ
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALL ED INSPECTION.
BUILDING ADDRESS
BUILDING USE
75-01-
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
NAME �7AtiC �Il OJT T/ia9�
HAZARDOUS ROOF
FIRE COVERING
AREA CLASS
EXISTING ROOF COVERING
ADDRESS f.0ii
PHONE r;? /OZ Y
NUMBER OF EXISTING COVERINGS 1
CONTRACCTTOR'Sp
7
NAME (T( iX d N I ✓LASON
TO BE REMOVED TO BE RETAINED —/<—
TYPE OF ROOF COVERING
ADDRESS
CITY & ZIP �OSYa2 %7LIN0 /lA�•—.4 .� • �l. %TO.�"D
EXISTING
PHONE 3•��'.�5��
BUILT -UP -ROOF
LICENSE 3G,3:O�
NUMBER
ASPHALTSHINGLES '
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby aNirm that I am licensed under provisions Of Chapter 9 (Com mem
ing wlm Section 7000) of Division 3 of the Business and Professions Code,
WOOD SHINGLES Y P
and my license'sJ?� fgll force and effect T
,a'. Class �L'�{�f Lia Number
Dale contractor
rector � �M1AI♦
'
OTHER (SPECIFY)
OWNER -BUILDER DECLARATION
"
I hereby affirm that I am exempt from the Contractor's License Law for
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
PROPOSED
unty which requires a permit to construct, alter, improve, deer isb,Or
repaelr
any structure, prior to its issuance, also requires the applicant for such
Permit to file a signed statement that he is licensed pursuant to the provisions
BUILT-UP ROOF
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Coda) or that he is exempt mere-
from and the basis for the alleged exemption, Any violation of section
ASPHALT SHINGLES
7031.5. by any applicant for a permit subjects the applicant t0 a Civil penalty
Of not more that five hundred dollars (500).):
❑ I, asowner of the property, or my employees with wages as their sole
WOOD SHAKES ��a L/ t4µ_ ,G 7 f S(/
"j
✓!G
Compensation, will do the work, and the structure is not intended or offered
for sale (Sec. 7044, Business and Professions Code: The Contractors License
WOOD SHINGLES
Law does not apply to an ownerveof property who builds or impros thereon,
and who does such work himselfor through his own employees, Provided that
such improvements are not intended P Peered for sale. If, however, the
OTHER (SPECIFY)
building o Improvement is sold within one year of completion, the Owner -
builder will have the burden of proving that he did not build Or improve for
purpose of . owner
❑ I, of the property, a exclusively contracting with licensed
PROVIDE I.C.B.O. REPORT NO.
contractors to construct tM1a project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply toanowner ofproperty
• who builds or improves thereon, and who contracts for such projects with a
PROVIDE MFGR. INSTALLATION SPECS.
contractors) licensed pursuant t0 the Contractor's License Law.
❑ 1 am exempt under sec. ,BAP.C. for this ason
FASTENER
Ow Data
WORKERSCOMPENSATION DECLARATION
I hereby affirm that I have a certificate of Consent to self. insure, o
tific a to of Workers' Compensation Insurance, or a car lied COPY m.reef (Sec.
3800, Lab. C.). �y
Policy No. Connote J/�%e ✓N
p eertifiod Copy is hereby furnished.
sur C rtif fed m fil%e �� the City inspection division,
'
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TYPE V � -CO
I
¢
/
LENGTH
'
FEE SUMMARY
A ant 6'''
CERTIFICATE EMP .� B
EXEMPTION FROM WORKERS'
COMPENSATION SATION INS
E
(This section needheANCE
not be complefetl If me permit is for one hundred dol
Iara (term Or that
1 certify [ha[ in the performance of the work for
i this permit is
" f
VALUATION
issued, ell not employ any person in any manner so as [o become subject
as
r
to the Workers' Compensation Laws of California.
Data Applicant
NOTICE TO APPLICANT: o alter making this Certificate of Eons ofion,
you should become subject [o the Workers' Compensation provisions me
Z
PERMIT FEE
WalibCode,w a
pea ned oxetl °rmwnh comply with such provisions Or mu permit
DATE OF APPLICATION
I certify that I have read this application and state that me above Informs
tion is correct. I agree to comply with all City and county ordinances and
state laws relating to building construction, and hereby authorize represen
[alive) Of this City to enter upon the above mentioned property for inspection
PERMIT VALIDATION
n
(�S
purposes.
(we) agree to say indemnify and keep harmless the city of Cupertino
against liabilities, judgments, costs and expenses which may in any way accrue
against said City in Consequence Of the granting of this permit.
SiC.9fT60%PWPO,itent/ ntract r 7.t
REQUIRED
PRE -INSPECTION
IN -PROCESS INSPECTION
h
FINAL INSPECTION
INSPECTIONS
INSPECTOR DATE
INSPECTOR DATE
INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY