R-0164 PERMIT CSA4
APPLICATION FOR CITY OF CUPERTIN NUMBERR. O16
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHI N 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
-
BUILDING ADDRESS BUILDING USE
Vl`�.J /� (M'(Yli� o I+ d✓r, RESIDENTIAL COMMERCIAL OTHER
OWNER'S
/n�A�.�- .�.�y( HAZARDOUS ROOF
NAME / P�' "' FIRE COVERING
AREA CLASS
ADDRESS " J � H�I t EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTO1\ TORE REMOVED
TO BE RETAINED
NAME
( / TYPE OF ROOF COVERING
ADDRESS, J A]_ v— .5, ,� Syor-
CITY&ZIP �`yYOV"' yor-)l EXISTING
PHONE
`/ yr-!�/5/y"D BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER �
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
hereby affirm that) of licensed under provisions of Chapter 9(comm an
aing with Section 7o0I' of Division 3 of me Business and Professigns C. WOOD SHINGLES
nd my license is;n r 1-q ce and effect QJy
License Class Lon NStith
Data - _ _ Civ- umber qr OTHER (SPECIFY)
OWNER-BUILDER DECLARAT ON
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 '
ocounty which requires a permit to construct, alter, improve, demonsb,pr
epolr any structure, prior to its Issuance also requires the applicant fpr such BUILT-UP ROOF
C. to f IS a signed statement that h is licensed pursuant to thep fns
of the Cor tractor S License Law (Chapter 9 (commencing ith Section 7000)
i7 P of Division 3 of the Business and Professions Code)or that he IS exempt there ASPHALT SHINGLES -
from and the bass for the alleged exemption. Any violation of Section.
7031.5 by any applicant for a permit Subjects the applicant to a 'I penalty
'
of not more that five hundred dollars($501 WOOD SHAKES
❑ I, as o of the property, or my employees with wages as their sole -
compensation,will a°the work, and me structure is not intended or offeree WOOD SHINGLES
for sale( Sec. 7044, r
.Business and Professions Code: The Contractor's License
Law does not apply to an owner Of property who bu;lds or Improves thereon,
and who does such work himself Or through his Own employees,provided that
such improvements are not intended or offered for sales II, however, the OTHER (SPECIFY)
bulld'mg or improvement Is sold within one year of completion, me owner OTHER
will have the burden of proving that he did not build o improve for,
purpose pa soien. PROVIDE I.C.B.O. REPORT NO.
I, s ower of the property, am exclusively contracting with licensed /
contractors to construct the project (sec. 7044, Business and Professions
ode: The Contractor's License Law d6asnmi lftoanownerofproperty PROVIDE MFGR. INSTALLATION SPECS.
Who.builds or improves thereon, and who contracts for such projects with a
contractors)licensed pursuant to the Contractor's License Law.
❑ I am exempt "neer Sec. ,B.&P.C.for this .FASTENER
Owne Date .
WORKERS'COMPENSATION DECLARATION URica (\^./� ' / S
M1eby affirm that I have a certificate of consent to sell insure,ora TYPE — ✓h C-0
re
Is of Workers' Compensation Insurance,or a certified copy thereof(Sec.
3800,Lab.CO.,. I i ter-_ /. t f�
Policy CNo,ar f company h'�sLVk"�`�' '�1°a`�CHs,"M
❑ Certified copy nen by wnnisn'e. LENGTH
� Certirea copy�yrl a wjm m tv Inspenipdaivisign.
A r1da°t—�s iTP FEE SUMMARY
CE RTIF ATE E MOTION FROM WORKERS' �J
COMPENSATIONmillet INSURANCEperm x i—s r•s,
(TMs section need not be completed it the permit is for one hundred tloh - G c5
ISIS($1 0)or that
i VALUATION 3,
certify that a the performance of the work for as
this permit is , A I
issued, shall not employ any person in any manner so as t"become subject
Solea Workers'Compensation Laws of California.
Date Applicant Yf7lTp
NOTICE TO APPLICANT:. 11,o after making this Compensation
provisions of Exofigq PERMIT FEE 4_
you should become su flet( i h c Workmplyars'h such provisi nshisa the
Shell be beamed you must comply with Such provisions or [M1Is permit DATE OF APPLICATION
'I certify that I nava read this application and state that the above informa
Thm is correct agree to comply with all city and county ordinances and /
state laws relat;ng to building construction, and hereby authorize represen-
tatives of this city to enter upon the above mentioned property for inspection
purposes.
(we) agnea T°-a ;ndemn'Ifv and keep harmless the city Of Cupertino ' PERMIT VALIDATION
against liabil ii;es,� gmeIn a_costs an xpenses which mey in any way accrue
egeinsi said Cityn n quant¢O} 1 g doting of this permit.
Signature of A li nt/Contractyq Data
REQUIRED PRE-INSPECTION - IN-PROCESS INSPECTION F
FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR DATE Ll INSPECTOR ' DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY