R-0202 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 0202
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMITISSUANCE OR
t 190 DAYS FROM LAST CALLED INSPECTION.
BUILDIN G ADDRESS/ BUILDING USE
OZ lMS /C4TX S RESIDENTIAL_ COMMERCIAL OTHER
OWNER'SHAZT
ROOF
NAME 1� 5j��1� 4�'2' ' - FIRE COVERING COVVERING
AREA CLASS
ADDRESS/0307— bS CAI)i WcN EXISTING ROOF COVERING
PHONE t{OA ZS3'- Z�F7 Z NUMBER OF EXISTING COVERINGS
CONTRACTORIS
11•• ,, TO BE REMOVED TO BE RETAINED
NAME W 1 u(�'('u5 (Zoor 11^9 LD _ � TYPE OF ROOF COVERING
ADDRESS
CITY&ZIP 165W (AS Off D95 l.C.)A/--f lxff"/�L°TWd
EXISTING
PHONE � � �i�3'•cT3 BUILT-UP ROOF
NLICENSE UMBER C{''`{O ASPHALT SHINGLES
WOOD SHAKES - �
LICENSED CONTRACTORS DECLARATION
I hereby affirm the,I am licensed under provisions of Chapter 9(common
ing With Section 70001 of Division 3 of he Business and Professions Code, WOOD SHINGLES
and my license is ir�III a and effect. 49Y
License Class ✓- Lic.Number h "_II OTHER SPECIFY
OWNER BUILDER DECLARA'TI�O'N
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
county which requires a permit to construct, alter, Improve, demoluh,or
repair any structure, prior to its issuance, also requires the applicant tar such BUILT-UP ROOF
Permit to file a signed statement that he is licensed pursuant to the provisions
of the 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 t(;,ere that five hundred dollars($5001.1: WOOD SHAKES the applicant t0 a civil penalty i
of he, I./
❑ 1, as owner of the property,or my employees with wages as their sole
compensation,wilt do inn work, and the structure is not intended or offeree WOOD SHINGLES
for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does riot 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 improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY) I
building or Improvement Is sold within one year of completion, the owner
builder will have the burden OI proving that he did not build or improve for )
Purpose of sale.l. PROVIDE LC.B.O. REPORT NO.
❑ I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
ode: ThaContractor'sLicense Law does not apply toanowner ofproperty PROVIDEMFGR. INSTALLATIONSPECS.
-no builds o improves thereon, and who contracts for such projects with a
contractor is)licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. ,B.&P.C.for his
axon FASTENER
Owner - Date
WORKERS'COMPENSATION DECLARATION -
1 hereby affirm that I have a certificate of consent to self-insure,or a car. TYPE lf'�1 X15
III,cafe Of Workeri Compensation Insurance,or a certified copy thereof(Sec.
3800.Lab.C.I.
Policy No. Common
® Certified copy is hereby wrmthed. - n LENGTH 2�
Certified copy is filed with the City inspection division. FEE SUMMARY C
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol- / Uv
ears($1081 or leas.) VALUATION •/K
I certify he, in the performance Of e k for which this permit is
issued, Shall t employ any personts�i P.
sa- to.scone subject
Io[he pTK,�q pensfum Lax; QI}i1 ifOr n/ ,('
Date Applicant j/ ///��•
NOTICE TO APPLICANT: If,raftgs making this Certificate of Exemption, PERMIT FEE Sa S--U S4/,P1y,C. S�
you should become subject to the Workers Compensation provisions of the
shall be doomed revoked orhwilM1 comply with such provisions or this permit DATE OF APPLICATION
I lordly that I have read this application and state that the above informs 1
tion is or
ogres - comply with all city and county ordinances and
state law la[i B to building construction, and hereby authorize Aquiline !I
kp.rp
ty[o enter upon[M1e above mentioned property for inspection S
naeys,C- i.',y, nd keep harmless the city of cuperlmn PERMIT VALIDATION
ry mnd expenseswmm they in any way accrue
nsop gaming of this permit.�I
Signature of Applicant/Contractor
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
. 'INSPECTIONS INSPECTOR DATE h INSPECTOR DATE INSPECTOR DATE .
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY