R-0191 PER MIT
a.-
APPLICATION FOR- -- '==CI-TY OF CUPE'RTINO-- � NUMBERR-i"" 9� -
REROOF PERMIT INSPECTION DIVISION
PERMIT EXPIRATION f
PERMIT EXPIRES IF WORK ISNOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
s IBD DAYS FROM LAST CALLED INSPECTION, i
'y BUILDING ADDRESS BUILDING USE
RESIDENTIALCOMMERCIAL" OTHER
pi
OWNER'S
n`/ /] HAZARDOUS ROOF
NAME f7 !/ [�G.(J FIRE COVERING
/� '/ AREA CLASS
,,ADDRESS; � i0 C Uhf 70���7` - EXISTING ROOF COVERING
�. � I /
�r�_-+ f , �/�. `� h; O::'�] F� NUMBER OF EXISTING COVERINGS
PHONE-r•.+. C,4r,2'CONTRACTOR'S •� ��
���/N� �a.^ TO BE REMOVED TO BE RETAINED
~ NAME �/�y n,r�y�l�L�,.C�n // /n� TYPE OF ROOF COVERING
+- CITY&Zia 1LZL 1y C 7''Ji_ EXISTING _
•PHONE BUILT-UP ROOF
• �� 7' ��y0
:DICENSE"� ASPHALT SHINGLES
NUNWOOD SHAKES f/
LICENSEatI-am XI icari .do, DECLARATION
a rfia^S'ufw reby affirm 1000 I em r ile.6 n f t Provos ons of Ohaptee9 ons Coca
-
and
m ,li action )000) of Din 3 on 3 of me Bnana::and Professions cede, WOOD SHINGLES
•',^'3 0 and'my license is Ih -r �d affect
Litters..cies ^FC9c Number
142137D
c � Date — contrapmr Z OTHER (SPECIFY) '
O N RBUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor, License Law for PROPOSED i.
the following.reason. (Sec. 7031.5, Business and Professions Code: Any city _
unto whichrequires a permit 10 construct, alter, improve, demolish,or
repair any structure,prior to its issuance,also reoeirez me applicant for such BUILT-UP ROOF
permit to rile a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) - ' +•-
ofDivision 3 of the Business and Professions e.dm.r that nes exempt mare ASPHALT SHINGLES
from and.the bass for No alleged.exemption. Any violation of.Eection .,,
7031 5 by any applicant for a permitsubjts the applicant to a civil penalty
0 of riot moxa that five hundred dollars($500L): WOOD SHAKES
1. p ❑ I, as o er of the property, or my employees with wages as their sole
cont transition,will do me work, and the Structure is not intended or offered .WOOD SHINGLES
for sal. (Sec. 7044, Business and Professions Code: The Contractor's License
Law does n0[apply t0 an Owner Of property who builds Or improves hereon,
and who does such work himself Or through his own employees,provided that
such irhprovnmarnts are not intended or offered for sale. If, however, theOTHER (SPECIFY) ��
1 buiTd g'.oPiovemedl-ii ToIB wrm n one Year of Com Fletrb!{'rtHO'OW r- tT�^'-.
huilder will have.1he burden of proving that he did not build or Imp o e for �rT
pare 0ofiale) -� - .1 , �PROVIDE I.C.B.O. REPORT NO. �..
• - n❑ r f +h p p rty nvely O t I' 9 w to licensed
- sy
'co tractors to construct the proper, (Sac '1044, Business and Prdfesz o P
ode: Tna Contractor's License Law does not Imply 1.an owner of property -PROVIDE MFGR. INSTALLATION SPECS.
nob Int or improves thereon and ho- o``oro ,s forsuch o t with a
out arm (sl licensed- 'P Su nt U, CrentracharI C -se Law.
_0 1 am'exdmpt oda Sec..' ,8.&PC logthii_
eason • - •.,.•.- —__.. fASTENER-=......
.
Owner Data
WORKERS'COMPENSATION DECLARATION
to ON /� 4��/��
hereby affirm that have a certificate or consent to sell.inm rat or a car. .TYPE ((//d. JsH"
._ ..gill.alero6Wo.kers' Compen aon•lend�r`ance,or.a certifiad c.p,thereof.ISec. ` ..
Pei Poi Lan 6f QeZ.Jj �,c.Y�57: G-�N�'ldy s
PlNo Qcam,ony ,,77 y� y 7��
❑ c (f ed copy h reby furnished. LENGTH 4L//�-.� 4 �.GC
+fieri copy t led with+n city inspect division,
Ap FEE SUMMARY
+ CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
'(This section need net be Completed if the permit is for One hundred dol
lets(stoo). last.) VALUATION /O Y�/•_
'Certify th I In performance f thework f h M1 m permit Is t -
i Issued H il_of employ a y pe so y roaren.,so a 1 become s:bl ct t >
to the Workers'Compensation Laws of California.
Date - Appl c t ! h r'. ayk'. L
NOTICE TO APPLICANT If, after making this Certificate of Exemption,
ofPERMIT FEE dle.�a
you should become subject i me Workers'h such provisions
provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
Snell be deemeB:evoked. "' DATE OF APPLICATION
I certify that I have read this application and state that the above inform.
non is correct. I agree to comply with all city and county ordinances and
state lawsrelating to building construction, and hereby authorize F.prmern
tatived,.of.th is city t0 enter upon the"ete ve-mr,n t i caned property for inspection
purposes.
(We) rine. saver. arrhy and keep harmless the sty of Cupertino PERMIT VALIDATION
..9,do f I lities,lu gme .zaxpees m
nd enswn cn may any way accrue ,y, -. `hl
gains of Gh, -I o ell thggrant a of this parmi
s� Signature Of ApplicanVCon[rector Date , -?
L, PRE-INSPECTION IN-PROCESS INSPECTION - FINAL INSPECTION
REQUIRED
INSPECTIONS INSPECTOR DATE_ INSPECTOR DATE INSPECTOR DATE
It
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY