R-0156 1
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" 5 r � PIUMBER
ERMIT R_ 0156
"APPLIC�ATLON_FOR'- . CITY OF CUPERTINO
~ REROOFPERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• `` ISO DAYS FROM LAST CALLEO INSPECTION.
BUILDING pADDRESS ¢ )p BUILDING USE
RESIDENTIAL_ COMMERCIAL OTHER -
�- OWNER'S '
4 I/ q - HAZARDOUS ROOF
NAME- itel :0 P�K• Xi ,FIRE - `COVERING
• AREACLASS
EXISTING ROOF COVERING
ADDRESS /� /�A'(•�ff/7/ I ( .u/Ji� �it.� 7�0 T _
PHONE 7 — OOD NUMBER OF EXISTING COVERINGS
CONTRACTOR'S — -
- ' " --•�--x-^TO BE'REMOV,ED--'� -�-•TO.BE RETAINED
NAME ! _,4G/FO.eN/A OAF/,JPS '
TYPE OF ROOF COVERING'
ADDRESS, -
CITY&ZIP /S9s — /C7t;,, Jf JJ ,),T'i <;;I,-//7— EXISTING
BUILT-UP ROOF ✓ C->eAd£G
r
PHONE—
LIC
HONE a93- �9�� �.
LICENSE
ASPHALT SHINGLES
NUMBER 7`1900 WOOD SHAKES
L I CENSE D CONTRACTO RS DECLARATION
I hereby affirm'hat I am licensed under provisions of Chapter 9(commen
aFling with section 7000) of Division 3 of the Business and Pirell ions Code, .WOOD SHINGLES
nd my Iearls is 11 force and affect.
Date
class Lie-breir Number i ! OTHER (SPECIFY)
Dale 41� 49 conna=lgr JG
OWNER-BUILDER DECLARATION
hereby affirm may 1.am exempt from the Connector's License Law for PROPOSED
me following reason (Sec. 7031.5, Business and Professions Cc an Any city
Or county which requires a permit to construct, alter, improve, dem°bsh,°r �J
repair tem,structure, pn°! t°its iss aPro, also requites ma applicant far such BUILT-UP ROOF
C oadC�'LfIS /�-pa?5�n
Permit t0 file a signed statement the,he is licensed p.rzuanl to m¢provisions
.'! o1 the Contractor's License Law (Chapter 9 (commencing with Section 7000)
t' of Division 3 of to Business and Professions Code)or ma,he is exempt mere ASPHALT SHINGLES
from and the basis for he alleged exemption. Any violation Of Section
W
III"' 7031.5 by any applicant for a permit subjects the applicant a civil penalty
!� '=•,
of net mere that five hundred dollars(55001.): WOOD SHAKES
- ❑ I,a of the Property, Or my employees with wages az their sole
ro
Corepeati illI do the work, and the structure is not intended or offered WOOD SHINGLES
for solo (Sac. 7044, Business and Professions Code: The Contractor's License ^
Law does not apply t0 an owner
of property who builds Or improves thereon,
and who does such work himself or through his own employees,provided that
such improvements are not intended a offered for sale. If, however, the OTHER (SPECIFY)
bu Nd ng o mprovement sold within ro one Veer of completion, the owner
builder will have the burden Of proving that he did not build or improve for
purpose'Town PROVIDE I.C.B.O. REPORT NO.
❑ I, st the property, a_ exclusively swat,Business an with licensed
cen[(0et°rz [p construct the project'Sec. 7044, Business and Professions
i Cotle: The Contractor's License Law does not apply to an Owner of property PROVIDE MFGR. INSTALLATION SPECS.
Who builds or improves thereon, and who contracts for such projects with a
contracmr(s1 licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sep. ,B,&P.C.for ntis FASTENER
Owsner Data
WORKERSCOMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self-Insure,o TYPE STKOAi ll✓��A/l.0
fill ca,e of Workers Compensation Insurance,or a certified copy thereof(Sac.
T 3800, Lob. I. /�//
Policy No $371Im'�anvmA.s�,C
Y' D C rtified copy is hereby f urni5had. - LENGTH`- - --
�rtified copy's filed wit he
chv-�.�=don division.
Applicant 17,941,Cijv n),R mac F,nJ6 FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS' /
COMPENSATION INSURANCE JJ
This section need not be completed if the permit is for one hundred dab
tars($100)or Ia55 .) VALUATION
certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner sous to become subject
to mo Work.,. en
Compsation Laws of Celiforniann
Date - Applicant
NOTICE TO APPLICANT: If, after making ,his Certificate 0f Examption, 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
shell be deemed reveketl. DATE OF APPLICATION
I call that I have read this application and stale that the above informs
,,on is correct. I agree to comply with all city and county ordinances and
state laws relating to building construction, and hereby plho,ite represen-
Plives of this city to enter upon the above mentioned property for Inspection
purposes.
(Wel agree to save, indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
v against liabilities,judgments,costs•antl expenses which may in any way accrue OO p '
I[t ag ins, 'd City in conse nce of the granting-of this permit �jluld/4��`+ 304•
S4navbN1r 01 Applicant/Contract go Fr S�/SM/G S•��
ry REQUIRED PRE-INSPECTIO IN-PROCESS INSPECTION FINAL INSPECTION
'.F INSPECTIONS INSPECTOR DATE INSPECTOR DATE h INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY r