R-0186 PERMIT 1Q
APPLICATION FOR OF CUPERTINO NUMBER Ras-
CITY 0 1 86
REROOF PERMIT INSPECTION DIVISION P ERMIT EXPIRATION:
PERMIT EXPIRES F WORK IS NOT STARTED
— WITHIN 180 DAYS OF P ERMITSISSUANCE OR
180 DAYS FROM LAST CALLE%INSPECTION. '
1 BUILDING ADDRESS BUILDING USE
RESIDENTIAL• COMMERCIAL OTHER—
OWNERS ' / {
/v�SSHAZARDOUS ROOF
NAME "` FIRE COVERING
AREA CLASS
ADDRESS -11" EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
Io/ d Lv
CONTRACTOR'
NAME A,
TTO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
CIDTDY&ZIP �IJ7�L7 EXISTING 1.
PHONE //�d 967- Casio BUILT-UP ROOF
ASPHALT_SHINGLES
'NUMBER 7�p /�/ '
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
hereby affirm 7000 1
xlicensed sins Chapter
Q
e
oIng with Section 7000) of Division 3 of the Business and Profess onsCrude, WOOD SHINGLES S
nemicense nd close7x t-
Licey Class L .Nu9
oa, com.a<or OTHER (SPECIFY) k`
�AWREITIBIJIIEDEIR DECLAR TI N - �•!�' it
hereby affirm that I am exempt from the Contractor's License Law for
do.following reason. (Sec. 7001.5, Business and Professions Cede: Any city PROPOSED
orunty which requires a permit to construct, altar, improve, demolish,or lei
repo any structure.prior t0 its issuance,also requires the applicant lorsuch BUILT-UP ROOF. -
rheributto file gned statement that he.is.licensed Pursuant to the Provisions .-, ,
of the Contractor's Lnuips. L (Chapter 9 (commencing with Section 7000) 'T -7
of Div m
0 of e Business' d Professions s exempt o s C eel or that he pt there ASPHALT SHINGLES
from end the bass for to allegetl o pf n. Any vitiation of Sac,pn
J.
7081 5 by any,opplicant for a permit bj ctsme applicant fee e civil penalty - • '
' of dosimeter that five hundred dollars 1$50011. WOOD SHAKES
❑t 1,as Owner Of the property,Or my employees with wages as their sole L'
tom pensatlon, will do the work, and the structure is not intended or offered
for,-sale (Sec. 7044, Business and Professions Code: The Contractors License WOOD SH INGLES
Low does not apply to an Owner of p p ty h0 builds or Improves thereon -
and who does such work himself or through his n employees Provided that
such mprovementz are not intended offered for sale if, however, the -�
build'no or improvement is sold with- owner OTHER (SPECT F.Y
builder will have the burden of V onot build or the o n ayv V� v;
purpose of sale 1 proving that h did not build Or improve for pr.•
❑ 1, as r of the property, am exclusively contracting with licensed PROVIDE, I.C.B.O.1,REPORT NO.
on
ctractors to construct the Project (Sac. 7044, Business and Professions i4 !S�� I '
codr
e: TheContra<totLicenseLawdoe,no,spot,upan..he,ofProperty PROVIDE.MFGR. INSTALLATION SPECS. •"
who builds or improves thereon, and who contracts for such Projects with a
<omractil licensed Pursuant to the Contractor's License Law.
❑ I an, ex mpt under Sec. ,B.&P.C,for this '
_ ,owpe - e - _ _ DP7P - FASTENER
WORKERS'COM P ENSAcare DECLARATION
1 hereby Workers'
that 1 nava i eerwman , consent ie saltily:ere, of(cert. TYPE
silicate of Workeri Compensation Insurance,are certified cope thereof(Sec.
8800
Leb
Policy NWorts^'4L-..Lafl ,/�� ,y ,` �+
-- ❑ aer,Blaa erode is naraby fury nec LENGTH A6G0'96e— ...D%I�C
•gDni+l a% rd yK �+v�Pect�ndvyon
{1A�plica { / / FEE SUMMARY
C FC E COMPENSATION
IO F5 RKERS i-
COMPENSATION INf t ANrm
(IS s )or lips.)
need not be completed f iM1e permit z for one hundred dol /� g�• e `•<
Tars IS 00) VALUATION "`�' 7 / `;
I certify that in the performance of the work for wnicM1 tM1 is parmi, is
issued, n I shall not employ any person in any manner so as to became subject
W
to the Workers'Compensation Lows of California. J 9
Data— Applicant
Amaking
/ a
NOTICE TO APPLICANT: If, It ak' g this Cerfficate of Exemption, PERMIT FEE
you should becomesubject t the Workers'Compensation provisions OI the r
Labor Code, you must forthwith comply with such provisions or this permit .DATE OF APPLICATION
shall be deemed revok d t om' '
Y .
t.rtifvcorrect.,
that I havagree
read,h s comply
t o a d state that the above ties ser T
t On R laws
rela agree t0 ng con W tM1 all city andher county ori ie rept entl /'3
state laws relating to enter
ung construction, and hereby arty f authorize aspected Q a vj/ '
tat vas ,. this city to enter upon me above mentioned property for inspection
purpose,.
I
Iwol agree to u� 1ym1ncity and keep harmless the City of Cupertino PERMIT VALIDATION.
against.! '1iHes,Isd n,L ostsit
a d ex Panses which may iany way accrue
ritf�t Q e granting of his p y
fir-,'�t.4 ` ISYS` �L ,�,�, 7
9naturo of Ap'plicont/Contractor Data a-7 -
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION v
INSPECTIONS
' INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
•NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY