R-0208 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 0208
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
tc WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAY$FROM LAST CALLED INSPECTION.
tri BUILDING ADDRESS BUILDING USE
0 Laos Dow K)At
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
NAME�� 2(/w'-K"rG/ HAZARDOUS _ ROOF
FIRE . COVERING
AREA CLASS
�� W EXISTING ROOF COVERING
ADDRESS /�� Ll � '�
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR�'/S) // a
NAME W ILI� S ' .OL'l j TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
ADDRESS,
CITY&ZIP 10?215( l,A!i D/I T)ii (,)04 1 • EXISTING
PHONE(V49) 993 — 54133 BUILT-UP ROOF
LICENSE N,7 09g ASPHALT SHINGLES
NUMBER _l WOOD SHAKESawl
LICENSED CONTRACTORS DECLARATION
I hereby affirm the,1 am licensed under provisions of Chapter 9(comma.
amg wish section 7000) of Dimsion 3 or me Rosiness and wofessions cine. WOOD SHINGLES
nd my license is in full force and affect.
License Class Lic.Number
Date Contractor OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the following re (Sec, 7031,5, Business and Professions Cody city e: An
or county which srequires a permit to construct,alter, improve, demolish,or
repair any structure,prior to its issuance, also requires the applicant for such BUILT=UP ROOF
permit to filo a signed s'element that he is licensed pursuant to the provisions
hi of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
t, of Division 3 of the Business and Professions Code)or that he is exempt mere ASPHALT SHINGLES
from and the basis for [he alleged exemption. Anv viplationeot section
7031.5 by any applicant fora permit subjects the applicant to a civil penalty f
n. of not more that five hundred do'
( 5001.): WOOD SHAKES AV
❑ I,as owner of the property, or my employees with wages es their sole
compensation, will do the work, and the structure is not intended o offered
for sale (Sec. 7044, Business and ProfessionsCode: The Convector's License WOOD SHINGLES
Lew do"not apply to an Owner of property Who builds or improves[hereon,
and who does such work himself or through his own employees,provided Net
qchimprovements are not intended or offered for sale., If, however, the OTHER (SPECIFY)
building or improvement Is sold within one Vast of compl elion, the owner
builder will have the burden of proving that he did not build Or improve for
purpose oa zoo o.n. PROVIDE I.C.B.O. REPORT NO.
❑ I, s of the property, am exclusively contracting w'Ith licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply toa owner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
WM10 builds of improves thereon, and who contracts for such projects with a
onlraClor(s)licensed pursuant to the Contractor's License Law.
❑ I am exempt under See. ,B.&P.C.for hisreason FASTENER
Ow
her De[e WORKERS'COMPENSATION DECLARATION !-has, '/ �/'-/�,r p�f
I hereby affirm that I have a certificate of consent to self.insure,or a car TYPE I�.•`7/O dU Diet _W#
tific ata of Workers' Compensation Insurance,or a certified copy thereof(Sec.
3800,Lab.C.I.
Policy NO. Company
❑ Certified copy is hereby furnished. LENGTH -Z I r
O Certified copy is filed with In.City inspection division.
Applicant FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(This section need Pat be completed if the permit is for ane hundred d.1-
en.(sloe)or less.) VALUATION
Certify that in the perform once Of t Work for w!!!!yyyy M1 this permit is
seed, aM1ell t ploy any person ipyn fuze sublee(
to Nowa. raIte bpmpensation Laws of(C a�} r`i a. T]{'
ly
Dale 12_[\� Applicant �a
NOTICE TO APPLICANT: If, site king this Certificate of Exemption, PERMIT FEE
you should become subject to the Workers'Compensation provisions of the
Labor Code,you must forthwith comply with such provisions or this permit
shelf be daemad revoked. DATE OF APPLICATION
I certify that I have road this application and state,tnat the above informa.
tion is correct ee to comply with all city and county Ordinances and
state laws rale g t building eonstruc[ion, and hereby authorize represent
tali visa Of th City enter upon the abovementioned property for inspection
pwposea -
( rae,to s nd ty and keep harmless the City of Cupertino PERMIT VALIDATION
aga�l Iia i(iiiea,f^�dg, en s,coasts and ex ppnsas Which may in�way accrue
ego i ai q an pf_lhe granting of this permit.
.�I $i !1/Of Appli<ent/COntrect0r Date I
REQUIRED L PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR DATL �O INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF S ALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY