R-0241i
PERMIT
FOR CITY OF CUPERTINO NUMBER R_ 0241
APPLICATION
INSPECTION DIVISION PERMIT EXPIRATION
•
RERODF PERMIT PERMIT EXPIRES IF WORK IS NOT STARTED
- WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
-
//�� '7[[
DOUS
�44lQ. oire!764%1
NAME /L
FIREAR
COVERING
AREA CLASS
%
EXISTING ROOF COVERING
ADDRESS
f
NUMBER OF EXISTING COVERINGS �� ^eW,(,,—riRcs
PHONE
TO BE REMOVED -f TO BE RETAINED
CONTRACTOR'S
MAdaa
TYPE OF ROOF COVERING
NAME [ Tor&o,)'
ADDRESS, � O(0.9 Y.1 ;9�yea29M9-�GS14'.Ocd0D00
CITVj& ZIP O(
EXISTING
353-.?x7r
BUILT-UP ROOF
PHONE
ASPHALT SHINGLES -
LICENSE 36.?30�'
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commen-
ing with Section 7000) of Division 3 of the Business and Professions Code,
WOOD SHINGLES.
and my license �s ul� 11 force and effect
License s Len. l
7K
Data COntrae[Or�G eilONIO a
OTHER (SPECIFY)
OTHER
OWNER -BUILDER DECLARATION
'
I hereby affirm that I em exempt from the Contractor's License Law for
PROPOSED
the fallowing re (Sac. 7031.5, Business and Professions Code: Any city
o linty whichsrequ ices a permit to construct, alter, improve, derr im,or
-
repair any structure, prior to its issuance, also requires the applicant for such
BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractors License Law (Chapter 9 (commencing withSection 7000)
A f Division 3 of the Business and Professions Code) or mat he is exempt there
ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violat'ronof Section
7031.5 by anyapplicant for a permit subjects the applicant to a civil penalty
of not more mat five hundred dollars ($500).1:
WOOD SHAKES C(�A/' h7liel�/vti
❑ Lea owner of the property, or my employees with wages as their sole
m pansation, will do the work, and the structure is not intended or offered
for sale (Sec. 7044, Business and Professions Code: The Contractors License
WOOD SHINGLES
Law does not apply t0 a owner Of property who builds or improves thereon,
own
and who does such work himself or through his o employees, provided that
lith improvements a not intended o offeree sale. It, however, the
OTHER (SPECIFY) -
building or improvement is sold within one year of completion, the on
owner
builder will have the burden of proving that be did not build or improve
pumoseolsela.).
PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am exclusively contracting with licensed
contractors to constructthe project (Sec. 7044, Business and Professions
Code: TheContractors License Law does not apply to an owner of Property
PROVIDEMFGR.INSTALLATION-SPECS.
who builds Or improves thereon, and who contracts for such projects with a
contractors) licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under S.C. ,B.&P.C. for his
reason
FASTENER
Owner Date
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to splLinsure, o
TYPE SnvL,O
pill Bale 0f Workers Compensation Insurance, Or a carlifietl copy thereof (Sec.
3800, Lab. C.1.if
Policy Npa�a'Q�� Company
d copy is hereby furnished.
LENGTH CIP
s�Carti
Car tified cop filed with t e city inspection division.
FEE SUMMARY
App "Ca"'CEPT �---�
CERTI CATS EXEMPTION FROM WORKERS'
E
COMPENSATION INSU RANCE
(TM1Is section need not hu completed it mo permit is for one M1untlmd tl01-
completed
7
jars ($1 Ogler less.)
VALUATION
1 certify that in the performance of the work for which this permit i
r
issued, I shall not employ any person in any manner so as to become subject
- -
[q the Workers' COmpensinum Laws of California.
'
Data Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
�y��
PERMIT FEE T -T � S�`�`%7iG % / a
you should become subject to the Workers' Compensation provisions of he
Labor Code, you must forthwith comply with such provisions Or this permit
DATEOF APPLICATION
shell be Cincinnati revoked. {
I certify that I have mad this application and state that the above informs.
tion is correct I agree 10 Comply with all city and county ordinances and-
state laws relating to building construction, and hereby authorize reprcrI-
G, �-
/
talives Of this city to enter upon the above mentioned property for inspection ,Po
-
PERMIT VALIDATION
purpose'.
(We) agree to save, indemnify and keep harmless the City of Cupertino
against liabilities, judgments, cast and expenses wM1ich may in any way accrue
age id id City in consequence of tfie grantlnill t s p rim it.
-
^ �l
at r pp is / actor Date
111"
PRE -INSPECTION
IN -PROCESS INSPECTION
FINAL INSPECTION
REQUIRED
INSPECTIONS
INSPECTOR DATE
INSPECTOR DATE
INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION