R-0198 PERMIT R- 0198
APPLICATION FOR CITY OF CUPERTINO NUMBER
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.
`f BUILDING ADDRESS - BUILDING USE
/
O RESIDENTIAL COMMERCIAL OTHER
OWNER'S or
B HAZARDOUS ROOF
NAME rjfA'e_. " FIRE COVERING
^� �^ AREA CLASS
ADDRESS U C v /"p - EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS o/,`
CONTRACTOR'
("� n TO BE REMOVED TO BE RETAINED
NAME � .•+ T"�Y�'SG UU� TYPE OF ROOF COVERING
ADDRESS, >
CITY&ZIP -Y 108` 9' -C.196 CEXISTING
PHONE r_^n// � —r l6 e-> / BUILT-UP ROOF
LICENSE /. }Q � � _ �3 ASPHALT SHINGLES
NUMBER �`�/ C. �a WOOD SHAKES X
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions Of Chapter 9(commem
tong With Sectio 7000) fa Division 3 of the Bosine,s and Professions code, WOOD SHINGLES
and am license- n fu fo And alfa¢,. O
License Class Lic.Number
of
Data Contactor of OTHER (SPECIFY)
O RBUILDER DECLARATIO
I hereby affirm that I am exempt troin,he Contractor's License Law for PROPOSED
the fon owing re (Sec. 7031.5, Business and Professions Code: Any city
Or county which ,requires a permit to c nstrvet, alter, improve, demolish,or
raper any Structure,prior to its issuance,also requires the applicant for such BUILT-UP ROOF
permit t0 fila a signed statement that he is licensed pursuant to the provi Sio ns
of the Contractor's License Law (Chapter 9 (commencing wilh Sacti.h 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
Y. 7031.5 by any,applicant for a permit subjects the applicant to a civil penalty
''. of not mora that five hundred dollars($500).1: WOOD SHAKES
❑ I,a of the property, Or my employees with wages as their sole or
nompontation, will do the work, and the Structure is not intended o offered
r sale (Sea 7044, Business and Professions Cade, The Contractor's License WOOD SHINGLES
Law Boas not apply to an owner of property who builds or Improves thereon,
and who does such work himself or through his own employees,provided that
such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building a mprovement is sold within One rear of completion, the owner
builder will have the burden of proving that he did not build or improve for
pu poseoat sale.).
a PROVIDE I.C.B.O. REPORT NO.
❑ I, st the property. a xcluSl44, contraction with licensed
pntrectgrt [p construct 0)Q project ($e[. 7044, Business and Professions
'
code: The Contracto:sLicense Law does not apply toanowner ofproperty *PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who contracts for such projects with b
ontractor(s)licensed pursuant to the Contractor's License Lew.
.❑ 1 am exempt undo, Sec. ,B.&P.C.for this
reason FASTENER
Ow Date
y her ` WORKERS'COMPENSATION DECLARATION
1 hereby affirm that 1 have a certificate of consent to self insure ora cer. TYPE
tificate of Workers'CompensationIim, n r tiff a py th of(Sec. 'fr�Cs
3800, Lob.C.I:s • �� T c o /I
3800, Na. �3--3,SYpanr / f
❑ cettined copy is here r mrnisnaa. LENGTH
Cattil opy' file f the t n erection tlivision.
�`aat-[[ �'� ai FEE SUMMARY
CEkTIFIC FROM WORKERS' ,
COMPENSATION INSURANCE E
(This Sec
ction n ed not be completed if the permit is for one hundred dol
Tars($1001 0r" A's.I VALUATION
I certlfy that in the performance Of the work for which this permit is
issued, I small not employ any person in any m er so as to become subject y
to the Workers'Compensation Laws of Californian
Date Applicant
NOTICE Id APPLICANT:. o after making this Compensation
ate of Eons ofithe PERMIT FEE W _S�C/J//C _
you shCod become subject i the Workers' Compensation provisions of Ino
Hopi be doomed re okuC annwlm comply with such pramslnns at this ra,mit DATE OF APPLICATION
I certify that I have read this application and state that the above informe
tion is correct. I agree to comply with all city and county Ordinances and
state laws relating to building construction, and hereby authorize represen a f�/`! 4•R
tatives of this city to enter upon the above mentioned property for inspection Cl
purposes. ' yds.
(We) agree to save, indemnify and keep harmless the City 0f`Cupertbto PERMIT VALIDATION
el.m. liabilities,rue ants,costs andin
again said y once o me g anongsof,his permit.any way accrue
.� - Slgnewra oaln ant/e ontrac,or �I
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
� � To