R-0240T.�
PERMIT o�AO
APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 4}
'REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /J o
BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
y/
q�
HAZARDOUS ROOF
NAME 4ic
A 7" �// (�./a/.�%/�
zg
FIRE COVERING
AREA CLASS
ADDRESS 75—x'3 is.+oV-�(" / "i!
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACT R'S
/ y �l
NAME L/L_/ fldT/6n C'
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
10,
/^
CITY & ZSP �ii�i/.zYlAk�//.�>F1q' l& 79H (
EXISTING
PHONE ��% Zli 7—,Zz,.2 s
BU LT -UP ROOF
LICENSE _
ASPHALT SHINGLES
NUMBER
WOOD SHAKES+
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (common.
ting with Section 7000) of Division 3 of the Business and Professions Code,
WOOD SHINGLES '
and my license is in'f i and effect. r
License Class t Number 7�(�� . _�
out. 1, _ �.�— Contract.,„SLS~Z'
OTHER (SPECIFY)
OWNER -BUILDER DECLARATION �
I hereby affirm that I am exempt from the Contractor's License Low for
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
PROPOSED
Linty which requires a permit to construct, alter, improve, demolizh,Or
repair any zt ructure, prior to its issuance. also rewires the applicant for such
permit to fila a signed statement that he is licensed pursuant to the Provisions
BUILT ROOF
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
ar Division 3 of the Business and Professions Code) or that he is exempt there
from and tno basis for the allegedexemption. Any violation of Section
ASPHALT SHINGLES
7031.5 by any applicant for a permit subjects the applicant t0 a civil penalty
of not more mat five hundred dollars ($500).):
❑ I, a owner of the property, or my employees with wages as their sole
WOOD SHAKES 1C
)—<
to m Panaation, will do the work, and the structure is not intended o offered
sale (Sac. 7044, Business and Professions Code. The Contractors License
WOOD SHINGLES
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 or offered for sale. If, however, the
OTHER (SPECIFY)
ti ng o improvement Is sola within o e year of completion, mr e owner
build at will ave the burden of proving that he did not build or improve for
Purpose of sale.). -
❑ I, as Owner of the Property, am exclusively contracting with licensed
PROVIDE I.C.B.O. REPORT NO.
t0 construct the project (Sac, 7044, Business and Professions
c.ntractors
ode: The Contractor's License Law does not apply to an owner of property
who builds or improves thereon, and who contracts for such projects with a
PROVIDE MFGR. INSTALLATION SPECS.
contractors) licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec. ,B.aP.c. for this
FASTENER
ne Date
WORKERS' COMPENSATION DECLARATION
hereby affirm that have a certificate of consent ie sell insure, ora
t hcote el Worker ' Com tion Insurance, consent
opy thereof
3800, Lab. C,)S'��� J;
Policy No. Company ��•M_�-� c
Certified copy is hereby furnished.
Certified Fogy is ]jfad wij(iFhe city in �6tio .. biyQf. O
3ql
TYPE 102/ Lf(% ,¢U �<?S
—y
/
n //
LENGTH
art
F. -EE SUMMARY
APPbcam�/N !� ie -'/wE �, .._.. �_
CE RTIF ATE OF EXEWf PION FROM ORK E RS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol-
Iare IS 00) or mss.)
I certify that in the performance of tn. work for which this permit is
VALUATION
issoI shall not employ any person in any manner s0 as t0 become subject
tothe Workers' Compensation Laws of California.
”
Dace Applicant
NOTICE TO APPLICANT: If, after making this certificate of Exemption,
you should become subject to the Workers' Compensation provisions of the
PERMIT FEE ..) �o ✓ J'`�.i�—i/C. �c
Labor
e l be deemed of inked�ormwith comply with such provisions or this permit
DATE OF APPLICATION
1 certify that 1 have read this application and state that the above informs
clan is correct. I agree to comply with all city and county ordinances and
state laws relating to building construction, and hereby athra
uoniz. preson-
%
8G 7/O
[olives of this city to enter. upon the above mentioned property for inspection
r'
,
a PERMIT VALIDATION
purposes.
Iwo) agree to save, indemnify and keep the
against u.mufles, judgments, costs and expenses which may in env way accrue
eswhi h in any ayCupertinoaccrue
agars ,z.m City n aquena. meter flag of_his permit
2-5-�_5
'
IBrIBlY6l-P, Can' LC110 p
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