R-0177 PERMIT _ 0177
APPLICATION FOR CITY OF CUPERTINO NUMBER R
REROOF PERMIT " INSPECTION DIVISION PERMIT e ORKI N
WITHIN 180 AY IF WORKIS NOTSTARTED
WITHIN180FROM
OF PERMIT INSPECTION.
BUILDING
t t•j1� �" 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
J1RESIDENTIAL COMMERCIAL OTHER
OWNER'S
`/ HAZARDOUS ROOF
NAME //LR CA •, e, FIRE COVERING
4�5
LLI�/ AREA CLASS
ADDRESS ' L /�/-(/( EXISTING ROOF COVERING
ff /� �/
PHON �S✓ 7 'Y Z� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED O TO BE RETAINED
NAME .?I"F.01—
n ) TVPE OF ROOF COVERING
ADDRESS, 6,6j6 44{l� �„
CITY&ZIP '/ EXISTING
PHONE �Ioy 7silli 111,4 BUILT-UP ROOF
LICENSE ,[t ASPHALT SHINGLES x
NUMBER 7J
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I of Division
under provisions of Chapter s(coons Code,
` cn with license
iso i fit of Dndmn 3 of he tipsiness d Professions code, WOOD SHINGLES
tine my license is'n 0)(f arra and affect. �/l
License ss Lic.Number
Data cpnnaptplt)�Y„ct' OTHER (SPECIFY)
OWNER-BUILDER DECLARA 10 l W
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
Or county which requires a permit to construct, alter, improve, dent isb,or
repair nv nructpre, prior to Its issuance also requires the applicant for such BUILT-UP ROOF
permiteto nla a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) s/
'Of Division 3 of the Business and Professions Code)Or that he is exempt there
.,.., � from and the basis for Cha alleged exemption. Any violation of Section
ASPHALT SHINGLES
�• 7031.5 by any,tip p l lcent fora permit subjects the applicant to a civil penalty
t of not more that five hundred dollars($500).1: WOOD SHAKES
C] 1, a owner of the property, or my employees with wages as their sole
cpm pansy t l Dor,will d0 the work, andthe structure is not intended Or Offered WOOD SHINGLES
for sale(Sac. 7044, Business and Professions Code: The Contractor's License
Law dyes not early to an owner
of property who builds or improves thereon,
and Who does such work himselfOr through his own employees,provided that
such improvements a not intended p offered for sale. If, however, the OTHER (SPECIFY)
building oimprovement is sold within one year of completion, the owner
builder will have the burden 01 proving that he did nor build Or improve for
Pumosem sale.). PROVIDE LC.B.O. REPORT NO.
L] I, a of the property, a exclusively contracting with licensed
actors to construct the project (Sec. 7044, Business and Professions -
coOtle: The Contractor's License Law does not apply to an owner of Property PROVIDE MFGR. INSTALLATION SPECS.
Who build or improves thereon, and who contracts for such projects with a
contractor(s)Sic round pursuant to the Contractor's License Law.
❑ 1 am exempt no., Sec. ,B.&P.C.for his FASTENER
Own° Data
WORKER"'COMPENSATION DECLARATION /J
1 hereby affirm hat I heva a certificate of consent to self-insure,or a car. TYPE 1/aI
tificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.
3800,Lab.CO.
Policy No. Company A
Car tnled copy is hereby furnished. LENGTH
Certif ed c py is f led wih mien divislo
App"`a n' FEE SUMMARY
CE TI FICATE OF EXEMPTS F OM WORKERS'
COMPENSATION SURANCE
(This mction need not be completed if the permit is for one hundred dol- /�Sik��
but($100)or Iti VALUATION (�
I certify that in the performance of the work for which this permit is
issu ad, 1 shall not employ any person in any manner so as to become subject
D the Workers'Compensation Laws Of California.
n �
Date Applicant /y
NOTICE TO APPLICANT: It, altar making his Certificate of Exemplum,' PERMIT FEE
you should become subject to Cho Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
shelf be deemed revoked. a DATE OF APPLICATION
certify that I have read this application and stale that the above informs k PAID '
[ion is correct. 1 agree to comply with all city and county ordinances and
state laws relating to building construction, and hereby authorize represom
fences of his City 10 enter upon the above mentioned property for inspection
purposes.
(Wel a ea isave. indemnify and keep harmless he City of CupertinoVVIMI LIDATION
again sl ties,j dgments,Costs and expenses which may in any way accrue
if . s Ci{y e f th quem ting of this permit.
p (�/may° y�/ City of Cupertino
Signature /Coglrz oS Data
REQUIRED PRE-INSPECTION IN-PROCESSINSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
[NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY