R-0199 PERMIT R_ 0199
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION P ERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
1 Y
. r BUILDING ADDRESS BUILDING USE
—7y 10 944 —4l entjiaiii Q Q'r ' RESIDENTIAL ✓ COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME ✓� s' FIRE COVERING
AREA CLASS
ADDRESS
S4 tic EXISTING ROOF COVERING
ZSZ �5 NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOCR'S -
(� TO BE REMOVED - TO BE RETAINED
NAME c.l 1 �—C-- ocI�.`.,o. TYPE OF ROOF COVERING
ADDRESS,
CITY & ZIP "'(ZZ EXISTING
PHONE �ti(Sl (x,51 —�37 ( - BUILT-UP ROOF
LICENSE _�_;7Cl _.J�� ASPHALT,SHINGLES
NUMBER
- WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(comment
Ing with Section 7000) of Division 3 of the Business and Professions Code, WOOD SHINGLES
and my lie a Is in full for o and effect.
License CI s Lic Number O
Dat. - 22 1 Contractor�,r�s`— OTHER (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
Linty which requires a permit to construct, alter, improve, demolish,or
repairanyenv structure, prior to its iss nc also requires the applicant for such BUILT-UP ROOF
permit t0 file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
�.. of Division 3 of the Business and Prolessions Code)or that he is exempt mere ASPHALT SHINGLES
I from and the basis for the alleged exemption, Any violation of Section
P 7031.5 by any,applicant for a permit subjects the applicant to a civil penalty
= .;` of not more that five hundred dollars($500).1: WOOD SHAKES
❑ I,as owner
of the property,or my employees with wages as their sole
fompensiniion,will do the work, and the structure is not intended or offered
r sale (Sec. 7044, Business and Professions Code: The Contractors License WOOD SHINGLES
Law does not apply to an owner of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that
such improvements tare not intended or offered for sale. R, however, the OTHER (SPECIFY)
bur
ilding O improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
purpose of sale.). PROVIDE LC.B.O. REPORTNO. 2 �OC/
[:j 1, a 1
r of the property. a xelusively contracting with licensed r r
contractors to construct the project (Sec. 7044, Business and Professions
ode: The Contractors License Low does not apply to an owner of Property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improve$ thereon,and who contracts for such projects with e
cenlractor(z)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under See. ,B.&P.C,for this FASTENER
reason
Owner Date
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self„mure,or agar. TYPE
lificate of Worker'Com ^Ballon Insurance,orecertifietl copy lhereol lSee.
-3800, Lab.C.IQ[fj- �1'3Y eQp
Policy No. Company IZCY4 l Za^7s"�~�•�'L�-
[7 CertiI d copy hereby furnished. LENGTH
�] Cerld y pled t y' spection di vision.
Ap-pTca"` s s. I t�O FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred Cob r j _
lar,($100)or has.) VALUATION
1 certify that in the performance of the work for which this permit is 4
issued, I sM1all not employ any person in any manner so as to become subject
To
the Workers Compensation Laws of California. S.
ate Applicant
D
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,- PERMIT FEE .jL--"/ V&4/r
You should bee subject to the Workers' Compensation provisions of the
Labor Code,you become
forthwith comply with such provisions or this permit DATE OF APPLICATION
shall be deemed revoked.
certify that I have road this application and state that the above informs
tion is correct. I agree to comply with all city and county ordinances and p
state laws relating to building construction;and hereby authorize represent 714
uatives of this city to enter upon the above mentioned property for inspection
purposes. p PERMIT VALIDATION
IWpI agree to save, indemnify 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 permit.
/•`/� (/�'Z�
Ile
Signature of Applicant/Contractor Data
REQUIRED PRE-INSPECTIONIN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR 01 TINSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY