R-0183 PERMIT R_ 0183
APPLICATION FOR CITY OF CUPERTINO NUMBERIll
REROOF PERMIT
INSPECTION DIVISION PERMIT E ORK1 N
PERMIT EXPIRES IF WORK IS NOT STARTED
• - 1WITH80 D N S F DAMS OF PERMIT ISSUANCE OR.
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
RESIDENTIAL 4� COMMERCIAL OTHER j
OWNER'S
HAZARDOUS ROOF
NAME �a� �w.//l/�S FIRE COVERING j
AREA CLASS
ADDRESS S _C� w�sss/ �. EXISTING ROOF COVERING
PHONE Zj Gr/ — NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
L / t TO BE REMOVED v TO BE RETAINED
NAME G/"; �ggi 41/C7 TYPE OF ROOF COVERING
ADDRESS,
CITY&ZIP I"" :�—L irso EXISTING
PHONE!Ii/�OS'�) �2Gg-�.2� BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER
WOOD SHAKES l/
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(comm en-
cmg with Section 7000) of Division 3 of me Business and Professi s code, WOOD SHINGLES
ane my license is in f u i ane effect.
License Class — Lic.Numbs on_5��1 OTHER (SPECIFY)
OatO
Contractorle
1C
NE RBUILDER DECLARATION ' TS
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 to construct,alter, improve, dem Olish,Or j
repair any structure, prior to 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 Secbon7000)
.� 0+ Division 3 of the Business and Professions Code)or that he is exempt mere ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violent on of Section
%f 7031.5 by any.applicant for a permit subjects the applicant to a civil penaltyy
�.v of not more that five hundred dollars($500).1: WOOD SHAKES
7Hti' ❑ I,as Owner Of the property.Or my employees with wages as their sole
fcore per= win do the work,and the structure is not intended or offeree WOOD SHINGLES
oor sale (Sec. 7044, Business and Professions Cada: The Contractors License
Law does not apply to an owner
of property who builds Or imp,OVOs Ih arson,
and Who does such work himselfor through his own employees,provided that
such improvements are not intended o offered for sale. If, however, the OTHER (SPECIFY)
building or 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 I.C.B.O. REPORT NO.
❑ I, as Owner of the property, am exclusively contracting with licensed
Contractors to construct the project ISeC. 7044, Business and Professions
Code: The Contractor's ucenseLaw does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who contracts for such projects with a
contracto r(s)licensed pursuant to the Contractor's License Law.n
❑ I e , exempt under Sec. ,B.&P.c,for this FASTENER
,.nor Date
WORKERS'COMPENSATION DECLARATION
heroby affirm that I have a certificate of consent to sell insure,or a car. TYPE
title to of Workers' Compensation Insurance nc certified copy iM1y sof S.C.
3800, NO. C.1. / /a ar r
3Policy800, Na. Company
certified copy Is hereby furnish— LENGTH
Certified copy js fil with the tv ins action tlivisipn.
A pI�=ant G/•,�-�x� ee �e .<� FEE SUMMARY
CE RTIFICATE.OF E%E MPTION FROM. RKERS'
COMPENSATION INSURANCE _
(TMs section need not be completed if the permit is for one hundred deb
lots 1$100)or less.) VALUATION S-SOD
I certify that in the performance Of the work for which this permit
lied, I shall not employ any person in any manner so as to become subject
10 4he We
rkers'Compensation Laws of California.
Applicant
ASa SE
NOTICE TO APPLICANT: If, after making this certificate of Exemption, PERMIT FEE _S� -Ct e- S
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such pro0isions or this permit
shall be dropped revoked. - DATE OF APPLICATION
certify mat M1ave road this application and state that the above Informix
tion is act agree to comply with a11.city and county Ordinances and
state laws r relating tO building construction, and hereby authorize represen
natives Of this City t0 enter upon the above-mentioned property for inspection
purposes.
(We) agree to s indemnify and keep hardi the city Of Cupertino ° PERMIT VALIDATION
against liabilities,judgments,costs and expanses which may in any way accrue
Tger t said City in sequence f granting of this permit.
'signate,e o heanve7,a
_. 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