R-0176 PERMIT Res 0176
APPLICATION FOR CITY OF CUPERTINO NUMBER v -t
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PEMWITHIN 180 DAYS OT EXPIRES IF F�PERM TORK IS'ISSUANCE OR\
`d. 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
997
RESIDENTIAL COMMERCIAL OTHER
OWNER'S IV
HAZARDOUS ROOF
NAME N'G!i`GC( FIRE COVERING
AREA CLASS
2/Itl�y `L ///,,, EXISTING ROOF COVERING
ADDRESS�7�-7 �i r � -
PHONE 47-1AV NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /J
D/11 A 16o �- �% TO BE REMOVED TO BE RETAINED
NAME r��LfJ LO`y��/��
TYPF OF ROOF COVERING
ADDRESS,
CITY&ZIP G ���� �� � � - EXISTING
1T J /--CC//VV
PHONE— M 71Z �(�3 BUILT-UP ROOF V
LICENSE < LL( 990 - ASPHALT SHINGLES '
NUMBER 7J
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I of licensed under provisions of Chapter Professions
s(nommen-
aine with saenon loam pr Division 3 of ma Business and Profession coca, WOOD SHINGLES
nd my license is fu f me and efface ��{
License CI zz Lic.Number
Date Contract., OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for
thefollowing reason. (Sec. 7031.5, Business end Professions Code: Any city PROPOSED
or my which requires a permit to construct, alter, improve, demolish,or � }-
epairruany structure, prior to its issuance_ also requires the applicant for such BUILT-UP RO Fua�!-' y
Permit to life a signed statement that he a licensed pursuant to the provisions
.y, of mmn
the Contractor's License Law (Chapter 9 (commencing With Xl
Z
Division 3 of the Business and Profusions Code)or that he is exempt there
m
from and the basis for the alleged exeption. Any violation of Section .ASPHALT SHINGLE
tv 7031.5 by any.applicant for a permit subjects the applicant to a civil penalty
± II of not more that five hundred dollar.Is500).): WOOD SHAKES
I, a Of the property, O my employees with wages as their sole -
Compensation,will do the work, and the structure is not intended o offered
r safe (Sec. 7044,Business and Professions Code: The Contractors License WOOD SHINGLES
Law does not apply to a r of property who builds Or improves thereon,
and who does such work himselfor through his Own employees,Provided that
such impr"yemanv are o intended p offered for safe, If, however, the OTHER (SPECIFY) ..
building O improvement is sold within one year Of companion, the Owner
builder will nave the burden of proving that he did not build or improve for
Purposeofsale.).. PROVIDE I.C.B.O. REPORT NO.
❑ I, of the property, am exclusively contracting with licensed
ontractorsto construct the Project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does riot apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds Or improves thereon, and who contracts for such projects with a
contracto r(s)licensed pursuant to the Contractiti License Law.
of I am ...rept under Sap. ,S.&P.C.for this FASTENER
owe Date
W ORKERS'COMPENSATION DECLARATION -
I hereby affirm that I have a certificate of consent to self insure,or a car.
tificate of Workers' Compensation Insurance,or ancertified copy thereof(Sec. TYPE
380X0, oto C y�QJ7S�CompenyST/Y '!O/nP iA/Sr Fu.aD
p�Carm�ed copv Is nerebv m.nisnad. LENGTH
r$Carolled yypy is filed with the city inspection division.
Ap ilea"' E�6 i FEE SUMMARY
CERTIFICATE OF E PTION FROM WORKERS'
COMPENSATION INSURANCE
(This section n ed not be completed if the permit is for One hundred Hot- � (r
Hot-
lots(slam or less.) VALUATION
1 certify that in the performance of the work for,which this permit is
issued, I shell not employ any person in any manner so as to become subject '
to the Workers'Compensation Laws of California.
Date Applicant 9 G (N _
NOTICE TO APPLICANT: If, after-making this Certificate of Exemption, PERMIT FEE oCe .SE/S/'1i�- % J�
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit li
shall be doomed revoked. - DATE OF APPLICATION
I certify that I have read this application and state that the above neforma
. tion is correct. I agree to comply with all city and county ordinances and
state laws relating to building construction, and hereby authorize represent ( (p
cunives orp 9001 this city t0 enter upon the above mentioned property for inspection
(We) agree to save, indemnify and keep harmless the City of CupertinoPERMIT VALIDATION
against liabilities,judgments,cons and expenses which may in any way accrue
against said y in consequence of the_granting of this 't.
t (tb 6
:�' Signature of Applicant/contractorractor 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