R-0184 PERMIT R_ 0184
APPLICATION FOR, CITY OF CUPERTINO NUMBER
REROOF PERMIT"' INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
"r WITHIN 180 DAYS OF PERMIT ISSUANCE OR
O. 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS. s t BUILDING USE
g� Oa / '�/. r o�/(/N •' 149 - RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME es, / G�� FIRE - COVERING
AREA CLASS
ADDRESS � J� ? - EXISTING ROOF COVERING
PHONE JDO e.7 L' ,O NUMBER OF EXISTING COVERINGS
_ CONTRACTORS
Y' NAME `t TO BE REMOVED .TO BE RETAINED
2B70
-Io / '-TYPE ✓✓✓
OF ROOF COVERING +
ADDRESS
CITY ESZ I; Qy7/�/ i17/ i/ir , �,� EXISTING
//P o GN �Vr ��
P PHONE7z� 9�,7-Reye � 9yDS'3 BUILT-UP ROOF
LICENSE / ASPHALT SHINGLES
NUMBER.. '-
_ WOOD SHAKES
LICENSED CONTRACTORS DECLARATION -
11nereby affirm that I em licensee and n prOvizicns Of Chapter 9(commem
'3
iiltg with Sactico 7000) of Divisionof'lhe'Busmess and Professions code, WOOD SH I NG LES
and.Pe ase is int II eeffect.
L ten Cle —� - L Number / e OTHER (SPECIFY)
Dam; Contractor
R BUILDER DECLA ATIO
lh by"a++i milrlM1 t I a exempt i ole the C0't crop's License Law for PROPOSED
the following re (Sec. 7031.5, Business and Professions Code: Any city
Or county whichrequiresa permit to construct, alter, improve,demolish,or
repair env structure, Prior to its issuance,also requires the applicant for such -BUILT-UP.ROOF�
Parto file a`signed statement that he Gucansee pursuant to in'.provismns - �
of the Contractor's L tensa Law (Chapter 9 (commencing with Section 7000)
r" $ f Division 3 of the Business and Professions Code)or that he's exempt there' ASPHALT SHINGLES
e f o and the basis for the alleged exemption, Any violation of Section
w+a:7031.51by any applicant for a perm t bl t -tM1a ppl cant to a civil penalty
of not re that,f ve no no red dollars($500).)4 - '❑x-I,more
owner of in property, or myf,erepl oy;e;with wages as to a lr so Ie WOOD SHAKES
m press t i on:w III"d0 the work land th e'stiucture is Aat intended a o,fared WOOD SHINGLES
for sale (Sec: m
7044, Business and.Pfessions Code:-The Contractor's License
Law does not apply to an OwneriOf property WI(o builds or improves iharder,
:and Who m does such work not int or ihrou9offer own employees,provided that /nJ n m TIL
,.
suchb.i ar
the,
improvomeov are not mmoead'o. offered of sale. I,, nothevoq the OTHER (SPECIFY) TieaJ
beild Ing it improvement is sold ovjh n one p'dfd of build
the owner
an
builtler will'M1ava the burden of proving'thagM1e'did not build or improve for
Purpose of sale.). - PROVIDE I.C.B.O. REPORT NO.
a
❑ I, s owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of properly pROVIDEMFGR. INSTALLATIONSPECS.
who builds a improves thereon, and who contracts ,or such projects with a
contrac[ora)licensed pursuant to the Contractor's License Law.
pas0on l am exempt under Sea. ,B.&P.C.for this FASTENER
owns Date
WORKERS'COMPENSATION DECLARATION
h r by if" 'that neva'e co t f' i i on t to If n lire
tf ;or a ter TYPE
,'Pew k s' Compensation on r acertified opyzthereof(Sec
Policy Ce Company
[] ca tip d pope be.mv t LENGTH 6
rj sy-'Car(f ed ,lyd wit jlTty bsp tion d vi:o .
[) ITpplieom-� //tiC FEE SUMMARY
CE OF P RS'
COMPENSATION INSU RANC �..�
(Tniz 9,or I need n0[be completed if the permit is for one hundred ea-
tars I$ rlif or lass.) VALUATION /a
1 cantly that in the performance of any
work for as which this permit is
issued, shall not employ any person in ny manner so as[o become subject OsE/SN/
z to the Workers'Compensation Laws of California. ..1
Data
Applicant T E -
'� NOTICE TO APPLICANT: 11, after making this Certificate o+ Exemption' PERMIT FEE
you should become subject to the Workers; Compensation provisions of the
Labor Code, you must forthwith comply With Such previsions or this permit
tx LS t:shatI be dappled redokpd.� °_ . t` w '' >DATE OF APPLICATION
a.
�I Cor ti I, the[ I nave read this appuca ti on and state that The above Informal
tion is correct. I agree to comply With all city and county ordinances and -.>
state laws relating to building construction, and hereby authorize represen / _?
relives of this city to enter upon the above mentioned property for inspection OC
purposes.
(We) agree to save, indemnify and keep-ha mless the City of Cupertino PERMITVALIDATION
against li Cilitips,judgen costs agd expenses w{licn may In any way accrue
age, 1. C}i+� co a ce f h granting this Permit.
:.L SiBnatura of Applicao ontra<tor Data r
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTIONFINAL INSPECTION
INSPECTIONS - .INSPECTOR DATE INSPECTOR SATE INSPECTOR DATE
NOTE: 'OSHA'APPROVED ACCESS TO ROOF SHALL-BEPROVIDEDFOR INSPECTION
INSPECTOR COPY