R-0234 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERRee O23A 4
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
11 (, 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS - -
BUILDING USE.,
1 �' - I
' 10421 Iaan6dale 'Ave. RESIDENTIAL COMMERCIAL OTHER
t 1 OWNER'S
John H. & Mar aret Coons— HAZARDOUS ROOF
NAME g FIRE COVERING
AREA CLASS
10421 Lansdale Ave., XISTING ROOF COVERING
' ADDRESS 1� � �i lPertln0 95OIL
PHONE 446-1747 NUMBER OF EXISTING COVERINGS one -
CONTRACTOR'S TO BE REMOVED TO BE RETAINED
NAME Security �ofing, Inc. TYPE OF ROOF COVERING
ADDRESS CITY&ZF rP. 0. Boa 2450, Menlo'-Park 94026 EXISTING�
PHONE 947-8811 BUILT-UP ROOF
LICENSE 306844 ASPHALT SHINGLES
NUMBER
WOOD SHAKES ]C8 Medium
LICENSED CONTRACTORS DECLARATION
1 hereby Section
that I oto licensed unser a Business
of chapters oho,ns Coca, WOOD SHINGLES
andwith Section )0001 of Division 3 01 the Business end Professions Code,.
and mV license is f and effect
DataLice .�qa�� Contra �O g' Y C OTHER (SPECIFY)
Date /�,/s?p cit..N.-.r
OWNER-BUILDER DECLARATION
I hereby affirm that I.am exempt from the contractors License Law for PROPOSED
the following res ($ec. 7031.5, Business and Professions Code: Any city
county whichrrequires a permit t0 construct, alter, improve, demoliall
\
repair any structure, prior to its issuance also requires the applicant for such BUILT-UP ROOF
A Permit to file a signed inuilu ent that he is licensed pursuant to the provisions
of lne Contractor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions code)or that he is exempt mere ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031.$by mV,applicant for a permit subjects the applicant to a civil penalty
of not more that five hundred dollars($sDw.): WOOD SHAKES x884$
❑ I,as owner of the Property, o,my employees with wages as their sola
compensation,will do the work, and the structure is not intended or offeree
for 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
such 'mprovements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building or improvement is sole within one year of completion, the owner. J Y
builder wlll have the burden of proving that he did not build ormprove for -.
purpose o0 sale')' PROVIDE 1.6'6.0. REPORT NO.
❑ 1, s owner of the Property, am exclusively contracting with licensee
ntractors t0 construct the Prole (Sec. 7044, Business and Professions ({ -
Coo
de: The ContractorCl s License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
Wh builtls O improves thereon, and who contracts for such projects with a It
convactorls)llicensed pursuant to the Contractor's License Law. ll
❑ 1 am exempt under Sec. ,B.a P.e.for this FASTENER
reason
Owner Dale
WORKERS'COMPENSATION�DECLARATION _ t
silicahereby affirm that'I have a certificate of consent to self-insure,or a car. TYPE
te of Workers' Compensation Insurance,or a certified copy thereof(Sec.
3800,Lab.
Pobcy Car — anushad. Opmzn- Til FnnA `
Car Red pv Iz hereby wminned' LENGTH
Certifieq,FF py filed wy n the ly inspecp0pp divisiPn. '
611
Amicant // o L o.le -
TIFICATE OG E EMPTI ON FROM WO FJERS' 4 FEE SUMMARY yf` Al
COMPENSATION INSURANCE i !P
(This section need not be completed if the permit is for one hundred dol-
lots($100)or less.) VALUATIONF. $55!468*W
certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner s0 as to became subject Ir 1
to mo Workers'Compensation Laws of California.
Dale Applicant $5b.50
NOTICE TO APPLICANT:sujen, ane, making this n Certificate p of Exemption. PERMIT FEE WK
you should become subject to 1M1e Workers'Compensation provisions of me
Labor Code, you must forthwith comply with such provisions or this permit
shall be doomed revoked. 1DATE OF APPLICATION
j I certify that I have read this application and slate that the above informs
hon Is correct. I agree to comply with all city and county ordinances and
stat. laws relating to building construction, and hereby authorize represen
latives of this city to enter upon the above mentioned Property for inspection
purposes. ..
(We) .gr.. m reelf. indemnify and keep harmless the city of Cupertino PERMIT VALIDATION
against liabilities,judgments,costs and expenses which may in any way accrue
epgins said 'ty in nsejylyBn e f tYngan till oft this permit.
it 1 DsI 8 20 85
g tort.o Ap tide ontranor Date r
E REQUIRED L
PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONI INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY