R-0197 PERMIT R_ 0197
APPLICATION FOR CITY 0E-CUPERTIN0 NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
` ! BUILDING ADDRESS BUILDING USE
10:5-71 ilk �� --,-/COMMERCIAL- COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME ����^� S FIRE COVERING
/I Vile
// AREA CLASS
ADDRESS /6 7 3 3 r — �P l� V /e k/ /1" l�G�' EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVE INGS
CONTRACTOR'S
/ n /' TO BE REMOVED TO BE RETAINED
NAME S� �wi //oa/ '%G - TYPE OF ROOF COVERING
ADRESL
CIITDY&Zip Q ����/�/j ��/� ��Hl..f�� EXISTING
PHONE -a)- V 2- BUILT-UP ROOF
LICENSEy� ��L/ ASPHALT SHINGLES
NUMBER // WOOD SHAKES ed'
i v.a-7
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensetl under provisions of Chapter 9 (common
ma With Section 7000) of Division 3 of the Business and Professions code, WOOD SHINGLES
and my license is ir,Tull f r and effect. <4/
O.haLi as:: - uc.Numbtactor OTHER (SPECIFY)
Lala /C Contractor
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for PROPOSED
the following reason, (Sec. 7031.5, Business and Professions Code: Any city
or county which requires a permit co construct, alter, improve, demolish,or 1.
wpav env!,tactors, Prior to its issuance also requires the applicant for such BUILT-UP ROOF
Permit to fila a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9 (commencing with Section 7000) f
of Division 3 of the Business and Professions Code)or m .a
at he is ex _pt there ASPHALT SHINGLES w
` from ane basis for of Section
7031.5d mme alleged exemption. Any violati O n by any,applicant for a permit subjects the applicant to a civil penalty
of not more that five hundred dollars(8500).): WOOD SHAKES
E] 1.as owner of the property,or my employees with wages as their sole
compensation,will do the work,and the structure is not intended or offered WOOD SHINGLES
Tor Salo (Sec. 7044, Business and'Professions Code: The Contractors License
Law does not apply t0 an owner OT properly who builds or improves thereon, _
and who does such work himself or through his own employees,provided that
such improvement! are not intended or
offered for sale. If, however, he OTHER (SPECIFY)
m
building Or improvement Is sold within one year of c pletion, the Owner
bull der will have the burden of Proving that he did not build or improve for
purpose of sale.). I PROVIDE I.C.B.O. REPORT N0.
❑ I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
_ coda: The Contractors 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
ontractpr(s) licensed pursuant to the Contractor's License Law.
❑ am exempt under Sec. ,B.&F.C.for thisreason FASTENER
Owner Date
WORKERS-COMPENSATION DECLARATION
I n hereby affirm that I have a certificate of consent m self insure,or ane
TYPE
tificaoe of Workers'Compensation Insurance,or acertified copy thereof(Sec.
3800,Lab.CO.
Policy ab Company
((II,�C.ertified cup,i M1 by w, LENGTH
_,Certified
tili atopy is fit wi,M1 I iinspaclion division. --
Applicant sr ,,f`I,-` `Z�...+ FEE SUMM!{RY rytJj
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE tY 0 /su
(This section need n0,be completed if the permit is for One hundred not 4
lots($ 00)or less.) VALUATION /lo GO-4/j pert%gyp
1 certify that in the performance of the work for which this permit i
issued, I shall t employ any person . any nor z s to ba oma su biti '
to the Werke C ropansation laws o} lilornia
Datf/3�� �F Applicant �P� Q.//_• �//-....; _/ /��--
NOrICE TO RPP LICANT: If, after making this Certificate of Exemption, PERMIT FEE 71115, VV
you should become subject to the Workers' Compensation provisions of me r.
Labor Code,you must forthwith comply with such provisions or this permit DATE OF APPLICATION
shall be deemed revoked, _ •�
I certify that I have read this applicationna d state that the above mforma
tion Is correct. I agree to comply with all city and county ordinances and /
state laws relating to building construction, and hereby authorize notated 7 !�
tatives of this city to enter upon the above mentioned property for inspection
Par(We) a y p - PERMIT VALIDATION
(We) agree to save, intlemnif 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 per
Signature of ApplicandCo tractor' OatOf ( �
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONSh INSPECTOR DATE_ INSPECTOR OATE I% INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SH LL BE PROVIDED FOR INSPECTION
INSPECTOR COPY