R-0163 J 1
PERMIT R_ 6
013
APPLICATION FOR CITY OF CUPERTINO NUMBER v
REROOF PERMIT
INSPECTION DIVISION PERMIT e WO
RKISoN
T STARTED
WITHIN 180 DAYS OFD RMTIISSUANCE OR
s 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/r�///�f �/ //ry'� S �j) Vin/ �/ BUILDING USE
/N 1 �`" J' "�D vis - RESIDENTIAL/- COMMERCIAL OTHER
OWNER'S ' / Q nQ/J
NAME V/`l`\NINil •` I�cSFIRE COVERING
SO�IV� HAZARDOUS ROOF
AREA ' CLASS
ADDRESS // �� /MS � �" EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS /
PHONE
CONTRACTOR'S �!1
NAME IF�A''�I (Lx gc'eo LD 14 TO BE REMOVED TO BE RETAINED
1✓ /�yj�,,�' -_�L � 1 ��(� TYPE OF ROOF COVERING
CITY&ZIP �� /J `J�'-+�'-• Wy ' �r" 'IYd EXISTING _
G f
PHONE Z� 1 BUILT-UP ROOF
LICENSELfC�L7�}�� ASPHALT SHINGLES ✓
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 hereby affirm 000 of licensed under provisions of Chapter Professions
s ons Code,
me with section 7ooB)force
Division a of the Business and Proms:ions cine, WOOD SHINGLES
and my license Is in full torte and effect.
License Class Lic.Number
Dela Contractor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm mal I am exempt from the Contractor's License Lew for PROPOSED
Ib. following r (Sec. 7031.5, Business and Professions Code: Any city
rrecounty which s rrequires a permit to c nstruct, alter, improve, demolish,or
pany structure, pilot m Its issuance also requires the applicant for such BUILT-UP ROOF
Permit to filo a signed statement that he is licensed pursuant to the provisions
F,- of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
o+ Division 3 of the Business and Professions Code)or that he is exempt mere ASPHALT SHINGLES
/ from and the basis for the alleged exemption, Any violation of Section
!lj•:' 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ✓
of not more mat five hundred dollars($500).1: WOOD SHAKES
❑ 1,as o of the property, o my employees with wages as their sole
mpeosation..iir
4i do the work, andthestructure is not intended or offered WOOD SHINGLES
'or sal. (Sec. 704 , Business and Professions Code: Th.Contrector'S License
law does not apply to an owner
of property who builds or improves thereon,
im
and who does such work hsalfor through his Own employees,provided that
buch improvements are not intended or offered for sale. 11, however, the OTHER (SPECIFY)
uild l no or Improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not bulla or improve,
for
purpose o+sala.l. PROVIDE LC.B.O. REPORT NO.
❑ I, s of the property, am exclusively contracting with licenses
contracto sto construct the project (Sec. 7044, Business and Professions
Code: TheContractorsucenseLawdoes not apply toanowner ofproperty , PROVIDE MFGR. INSTALLATION SPECS.
Who buiIds or improves thereon, and who contracts for such projects with a
contractor(s)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt Ander sac. ,B.aP.e.for this FASTENER
Owsne, Date
WORKERS'COMPENSATION DECLARATION
hereby arum that I have a certificate of consent to 00, self insure,ora TYPE
38 :o1 workers'Campensmm
ion In�ren ,Or a sonified c nv thereof
eof(sea d
3800, Lee.c,). L L (p��
Policy No. Company!
J'{p❑Q Carlired op�Y,i hereby+urmshod. LENGTH
App is Cert lr i.d cq{ry)`S Ila—d'wim—.tF,M1p�-yity ine—ion division.
I ant CEftTI �I lle�/ATE OF EXFMPA/TI FRDM wORI<E RS FEE SUMMARY
COMPENSATION INSURANCE - ^ c+'T0
(This section neva not be
COMPENSATION
completedi if the permit Is for one hundred Col- / ��
Iare($100)or Iew.) - VALUATION
1 certify that in the performance Of the work for which this pOrmit fff //
issued, I shall not employ any person in.any manner so as to become subject q�
I o the Workers'Compensation Laws of California. -e
Date Appllc ant l
NOTICE TO APPLICANT: If, after making this Certificateof Exemption, PERMITA&
You should become subject to the WorkersCompensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
:hall be deemed revoked. DATE OF APPLICATI,ON_.
1 certify that I have read this application and state that the abovencesinforma
and
MAY 1 4 1985 /—
Sian is correct. 1 agree to comply with all city and county ordinances reph and
stets laws relating to building c net ruction, and hereby authorize for rspction
pu ipo s. this city IO enter upon IM10 ebOVa mentioned property for inspection
proposes.
(We) agree to Saye ipdamm+v and keep harmless the sty of ay accrue'.. Bp2f#�jiMIT VALIDATION
against ties,jutlgm du ..1 and expenses which his may in any way eccru
_, against sa tl icy q��C of me granting of rots permit.
LY�c / S—/y—S / -7� v J
LL� Signet .f'Applicant/ onthactor Data
'REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION - FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY