R-0235 PERMIT R_ Q235
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT •INSP ECTFON DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK 15 NOT STARTED
Y. WITHIN 180 DAYS 05 PERMIT ISSUANCE OR
�F 180 DAYS FROM LAST CALLED INSPECTION. ,
• BUILDING ADDRESS BUILDING USE
10623 -Glenvim Ave. RESIDENTIAL XX COMMERCIAL OTHER j
OWNER'S
HAZARDOUS ROOF -
NAME Leo & Carol Lehner FIRE COVERING
AREA CLASS
ADDRESS 10623 Glenview Ave., Cupertino EXISTING ROOF COVERING
1-
f.�•2G3C NUMBER OF EXISTING COVERINGS one
4 ;1
PHONE 4 7
CONTRACTOR'S '
TO BE REMOVED TO 8E RETAINED
NAME Security Roofing, Int. TYPE OF ROOF COVERING
- L"
CITY&ZIP P. 0. Box 2150'24en10 Pei&; 'C3. 9liB26' EXISTING
PHONE 9474811 BUILT-UP ROOF
LICENSEp� �� ASPHALT SHINGLES n
NUMBER 3068Eali '
WOOD SHAKES" 7�IX
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9.(common WOOD SHINGLES
ting with Section 7000) f Division 3 of the Business and Professions Code,
and my license is
i tl Ifeco +
Lic....cls Li<.Numbe T,HER SPECIFY a
Data ry f c.mrecter� iLOOling� nCA - (SPECIFY)
OWNER-BUILDER DECLARATION '
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the.following reason. (Sec. 7031'5, Business and Professions Code: Any city
or county which requires a permit to construct, alter, improve, demolish,or C 1
repair any structure,prior m Its issuance:also requires the 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) "y
Xlct- of Divisiona of the Bus e s and'Professions Code)or that he-s Pr there-, ASPHALT SHINGLES -
from d thebasis'to the alleged exemption. violation Anyf Section. „
•• 7031 5 by Y applicant f permit subjects the applicant to civil penalty
a., of not more that live hundred dollars($5001 r p WOOD SHAKES MP..d9_uTn.:'. ,
I,as owner of the property, or my employees with wages az their solo
to tion,will do the work, and the structure is not intended or offered 1
msale ( WOOD SHINGLES
for le (Sec. 7049, Business and Professions Code: The or improves
mp oe s License
Lew does not apply to an Owner of property who n employees,
m Or i es, ores provided
that
end M1 d h work himself o through M1 o pl y ,Prov der mat
such improvements are not imended or ofor sale. 1f nother
OTHER (SPECIFY)
build 9 p eve sold lit one year 1completion, owner
builderII ba [M1e burden of proving m [he-did not build or improve
for
pPr0 S orsafe.).
- PROVIDEI.C.B.O. REPORT N� ^�
1 as owner st me property, exclusivelycontracting with Lensed
contractors to construct ice seLaproject (Sec 70app Business and Professions of property
Code: The s or
ProvContractor's hereon and doeswho cot tracts fe8uch pr acts ith a PROVIDE MFGR. INSTAbI,A�T10 SP•ECM S.
wno builds )l improves scant t,aha wno convects for such projects with a _ JJCt
contractor Is)licensed oder ant to mo Contractor's License Law.
I am exempt under sac. ,B.a P.c.for this FASTENER
reason 5
Owner Data / s
WORKFRS'COMPENSATION DECLARATION - J ,s oI
1 hereby arf rte mat 'haveoffi i '( o t to n�n TYPei1S '�upe�l/l0 �.
,,rate of WorkersCompensation Insurance,or a certified copy thereof(Sec.
3800, Lab.��1,��(�a�(.ay�a/�,�
Policy No,(j[O a finer, ,fta A rA111 Fund
JkECertified copy hereby h,rnlshed. LENGTH nails
.CertU1'ed copy's filed m f ty lnzp tion qiv Sion.
Applicant `E;Ls-ntyiTo pnv_ �` FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORT S'. .
COMPENSATION INSUR ANCE `ii -
(This z ch.h dead not be completed if the permit;is for one hundred dol- @�� '� ,
,1.rs IS 100)or laaa. ) VALUATION $4.469.00
I certify.matin the performance of the work'torwhich this Permit is
issued, I shall not employ any person in any manner so as to become subject
m the Workers'Compensation Laws of California.
Date Applicant r
NOTICE TO APPLICANT: If, atter making his certificate of Exemption; PERMIT FEE $51.00
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
sh.I1 be deem ad revoked:-_ I DATE OF APPLICATION
1 certify that 1 have read this application and state that the above informa.
tion is correct, I agree to comply with all city and county o d' e' tl
y(t�` "
slate laws relating to building construction, and hereby authorizen son :,'.- 9/6/85,
tatives of this city to enter upon the above-mentioned property for inspect on
purpose,.
(We) agree to save, indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against liabili-"�tiey,,�j Bme [rys, is and expenses which may in any way accrue
v a/�li n zesp ?j.f tirmentirRq[this P9 rD t/
85•.,� gn ure of'F)P-Plic�nfVClonlsrac6tyo)r1 4r lsJJJ Date/�
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 1
INSPECTOR COPY