R-0158 y I ;
PERMIT Rex 0158
APPLICATION FOR -CITY OF CUPERTINO NUMBER
INSPECTION DIVISION
RE ROO F PERMIT PRMIT E%PIRATION
'iv• PERMIT E%PIKES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF.'. IT ISSUANCE OR
ISO DAYS FROM LAST CALLED(INSPECTION.
' BUILDING ADDRESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S \ p.,,,,1� //�� � � �
NAME JAS J'C&Ji7ST HAZARDOUS ROOF
FIRE COVERING
AREA CLASS II
ADDRESS / �b� rv`—"'S`V'=� EXISTING ROOF COVERING
PHONE
PHONE NUMBER OF EXISTING COVERINGS (>J-CI
CONTRACTOR' -
I a�J/ TO BE REMOVED �` TO BE RETAINED
NAME �(i(/� l h'��T"`•� TYPE OF ROOF COVERING
ADDRESS,
CITY&ZIP /'11 / /aS U- EXISTING
PHONE—— ! / Y9� BUILT-UP ROOF
LICENSELL ASPHALT SHINGLES
NUMBER 7 ', �.G
WOOD SHAKES
LICENSED CONTRACTORS under DECLARATION
I hereby Section
00 of Division
under provisions of Chapters(coons Code,
amg with seceon loom or Division 3 of me Business and Professions Code, WOOD SHINGLES
nd my license is in fµfl mina and affect.
License ClessiS�'.f'. Lic Number==
x Date S�='� contractor aliiOTHER (SPECIFY)
OWNER-BUILOER DECLARATI
I hereby affirm that I am exempt from me contractors License Law for PROPOSED
the following reason,
(Sec. 7031.5, Business and Professions Code: Any city
or county whichrequires a permit to construe,, alter, improve, deem iffi,or
repair any structure, prior ,o Its issuance,also rewires ,he 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 therm ASPHALT SHINGLES
j✓ from and the basis for the alleged exemption. Any violation of Section
3I 1 7031.5 by any,applicant for a permitubjects the applicant to a civil penalty
of not more that five hundred dollars($504 .): WOOD SHAKES
I, as o ryeowner of the Property, o my employees with wages as Their sole
fomp ansa,ion,wl II do the work, and be structure Is not intended or offered
r sale (Sec. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
Law does not apply to an Owner of property who builds or improves,hereon,'
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 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 s oiwne PROVIDE I.C.B.O. REPORT NO.
I, r st the property, a elusively Contracting Pr licensed
Code:
The
to construct the project (sec, t app Business and Professions
Contractors
Ths or improves
License and doeswho cot tracts fon owner Projects
is with
PROVIDE MFGR. INSTALLATION SPECS.
who builds o eased pursuant
thereon,and who contracts for such protects witM1 a
pntract am licensed pursuant to the Contractor's License Law,
em exempt under Sac. ,B.&P.C.for this'
owowner FASTENER
Data
WORKERS•COMPENSATION DECLARATION / f I( �/��
hereby affirm that I have a certificate of consent to self insure,or a cern TYPE S�n`a �/� // C'a—i&,
titicato of Workers' Compensation Insurance,or a certified copy thereof(Sec.
3800, Lab.C,1.
Policy Company
Certified
is y
D Cerafiea copy is hereby w th the cid. - LENGTH
❑ C¢rli}ietl copy is tiled with 1M1e City inspection division.
Applicant FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCEy VV
(This section need not be completed if the permit is for one hundred dol �f iTll
ts(s1o0)orless.) VALUATION
I certify That in the performance of the work for which this permit is
issued, 1 shall not employ any person in any ner so as to become subject
to the Workers'Com inset ion Laws of C.life i
Data — Applicant Z
NOT( T A P (CANT: If, a❑et maki [ is Cenifi¢ o of Exemption, PERMIT FEE 3� S�- St/J i`ri n=
you should become subject to the Worker Compensation provisions of the
Labor Code,you must forthwith comply with such provisions or this permit
shall be deemed revoked. DATE OF APPLICATION
I certify that I have read this appl kation and state that the above ieforma. 3
ciao is Correct. Degree t0 ng con with all cityand and County aur ordinances and
state laws relating to building construction, imi hereby authorize for
f,eaclicen
on fives of this city to enter upon tM1a above mentioned property tOr inspection
perpWe)I agree
�(we) agree to save, indemnify and keep harmless the city or ay ateree PERMIT VALIDATION
ki S.;e liabilities,I 9m¢nts,costs d pens, which may in any way accrue
against saitl Ciry i mus to of th grantingsof,his permit.
sign„lira of AP' i annotto 0.1.
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION - FINAL INSPECTION
INSPECTIONS LL]]// Z
INSPECTOR DATE INSPECTO DATE INSPECTOR DATE
—NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY