R-0154PERMIT
APPLICATION FOR CITY OF CUPERTINO NU BER R- 0154
INSPECTION DIVISION
PERMIT EXPIRATION
REROOF 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
in, La W/9 bgZ
/2 ®
RESIDENTIAL_ COMMERCIAL OTHER
OWNER'S
/
HAZARDOUS
NAME /y/ S D2M
FIREAR
COVERING
AREA CLASS
EXISTING ROOF COVERING
ADDRESS SUS 3�i �,
,,/7a�I/-�
NUMBER OF EXISTING COVERINGS
-PHONE
'CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME T TO P R ton T /A
TYPE OF ROOF COVERING
ADDRESS,
CITY & ZIP Z2 l�C.2 /1-/Zt� /7 /2•
EXISTING
FoGSo �� C'� SSG 30
`7 '
BUILT-UP ROOF
PHONE /la 9 R i- 70 5
LICENSE . y J
ASPHALT SHINGLES
NUMBER 00
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
hereby affirm 1000 licensed under provisions of Chapter mem
of
me with Section T000l o+ Division 3 of tna Bu,'Ine aha Pmfessm s e
s o 1
WOOD SHINGLES
and my license's full f°rgp d effect.
License Clpz> 4r'n.f r 7 Lic, Number
Data s' 7, / &4i— Contract., G s�
OTHER (SPECIFY)
r' OWNER -BUILDER DECLAR ION
I hereby affirm that I am exempt from the C ntractoi s License Law for
PROPOSED
zr
the following r (Sec. 7031.5, 8usi pass an. Professions Code: An y. c i ty
recounty which requires a permit to construct, alter, improve, demolish,or
pair any Structure, prior to its Issuance, also requires trio applicant ter Such
BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
0+ th0 Contractor's License Law (Chapter 9 (commencing with Section 70001
Of Division 3 of the Business and Professions Code) or that he is exempt there
ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
Of not more that five hundred dollars 18500).1:
WOOD SHAKES
❑ 1, asowner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended o offered
r sale (Sec. 7044, Business and Professions Code: The Contractor's License
WOOD.SHINGLES -
Law does not apply to an owner.of property who builds or Improves thereon,
and who does such work himself or through his own employees, provided that
uch improvements are not intended o offered for sale. It, however, the
OTHER' (SPECIFY)
building p improvement Is sold within o no Va., of Completion, the owner
v
builder will have the burden Of proving that he did not build or improve
Purpose of sale.).
PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the property, am exclusively contracting with licensed
contractors t0 construct the project (Sec. 7044, Business and Professio n,
Cotle: The
PROV.IDEMFGR.INSTALLATIONSPECS.
who builtls or improves thereon, and who contracts for such projects with a
con t ractor(z) licensed pursuant to the Contractor's License Law.
❑ l am exempt under Sec, ,B.&P.C, for this
mason
FASTENER
Ow Data
WORKERS' COMPENSATION DECLARATION
I ranch, affirm that I have a certificate of consent to self insure, o
�+.
TYPE J Tq A /L S .
tificate ofWorkers Compensation Insurance, Or a certified copy thereof (Sec.
3800, Lab. C.).
Policy No. Company
�is
ereby mish.d.
C.rorpe cup, is hm
LENGTH i
Cea l red copy is filed with the city Inspection division.
FEE SUMMARY
Applicant
CERTIFICATE EXEMPTION FROM WORKERS'
-'
E (NSU
COMPENSATION S NCE
(This section hood not be completed it the permit is for one hundred tl01
millet a perm
pars (sloe) or le,,.)
VALUATION "
I certify that in the performance Of the work +°r II this permit is
_.3 si
issuetl, shall t employ any per a men to b om or act
hers
hall
iIr
to Na Workers' Com ion Laws f ornia. f
Data - j}Applicant
NOTIC TO APPL CANT: If, a5 akI g Wls 'ertificat of xemptloq
•sem �' /J/ //� " `-
PERMIT FEE (
you should become subject t° the rkerl Compensation provisions of the
must forthwith .o Iv with such provisions or this permit
_ r/
DATE OF APPLICATION
heli beeuavee ;p
I certify that I have read this application and state that the above informs
tion is correct. I agree to comply with all city and county ordinances and
stat.laws relating to building,construction, and hereby authorize represen
IDtives Of this city to enter upon the above mentioned property for inspection
purposes.
(We) agree fo save, pp moil, d k..p harm
a me Cis,. of Cupertino
PERMIT VALIDATION
e nst iabil sties, ju g 6n i..
costs an xpo as which may in any way accrue
a nn eitl city In wlua ca o t this permit.
'
Sig ecu re of ApplicenVContractor Date
F.
REQUIRED.
-PRE-INSPECTION
IN -PROCESS INSPECTION
FINAL INSPECTION
INSPECTIONS
INSPECTOR DATE
INSPECTOR DATE
INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY