R-0144 PERMIT R_ 0144
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
.' BUILDING ADDRESS V(,993 �C(C 1/A� / �' BUILDING USE
/ F til RESIDENTIAL COMMERCIAL OTHER
OWNER'S
��rr HAZARDOUS ROOF
NAMEJ/PN 5>P51/fh0:7 FIRE - COVERING
AREA CLASS
ADDRESS '� (d9� ptnCFAn/ 0? EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS (
CONTRACTOR'S , I //�,,, ,l�,_
NAME IS (I �r V� 7A/r�'Z �N /r`^rC � TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
ADDRESS,
�(7� �
EXISTINGCITY&ZIP (C � il 2
PHONE�`IJ'3� ZYS-' y�7 Z BUILT-UP ROOF
LICENSE /3 / /ZZ ASPHALT SHINGLES
NUMBER WOOD SHAKES s#net� s
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9(co
ing wim Scemment
Don 7000) of Division 3 of the Business and Professions Code, WOOD SHINGLES
end my Rcen se is in full force and effect.
License Class Lic.Number
Do,e contractor OTHER (SPECIFY)
OWNER BUILDER DECLARATION
1 hereby affirm that a exempt from the Contractors License Law for PROPOSED
the following reason. ISec. 7031.5, Business and Professions Code: Any city
roacounty which requires a permit to c h nstruealter, improve, demolish,or
pair ane struc,ure,prior to its issuance also requires me applicant for such BUILT-UP ROOF
perto file a signed statement that he is licensed pursuant to he provisions
of the Contractor's License Law (chapter 9 (commencing with Section 7000)
of Division 3 or the Business and Professions Code)or that he is exempt mere ASPHALT SHINGLES 0hA) 44A.vSV/11F
, •'. from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not mere that five hundred dollars($500).): WOOD SHAKES
r re', ❑ I,as ow r of the property, or my employees with wages as their sole
crup
topsail o n,will do the work,and the structure is not intended or offered WOOD SHINGLES
fm sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to an Owner Of Property who builds or improves thereon,
` xr`and who does such work himself or through his own employees,provided that
such improvements are not intended or offered for sale. II, however, the OTHER (SPECIFY)
building orimprovement is sold within one year of completion, the owner-
builder will have ,he burden of proving that he did n0[build or improve for
Purpose Of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as Owner of the property, am exclusively corprieling with licensed
contractors to construct the project ISec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property PROVIDE III INSTALLATION SPECS.
who builds o improves thereon, and who contracts for such projects with a
conhactor(s) Ilicensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec. ,B.a P.c.for this
reason FASTENER
Owner Data
WORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to selfinsure,or a cer. LYPE Af-*TF fi
[ificate of Workers' Compensation Insurance,or a certified copy thereof ISec.
3800, Lou.C,). �r
Policy No. Company
gCer[ifim copy is hereby furnished. LENGTH
Cer[i red copy is filed with the city inspection division.
Applicant
FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS' s PAI
COMPENSATION INSURANCE r
(This section need not be completed if the permit is for one hundred doh
lars($100)or Ies.J /W A3;
1 carefr mat in me performance m me work for whish this permit is VA lT1tIV\ION
issued. I shall not employ any person in any m so as to become subject
to the o Compensation Laws o)Cplijy Boner
Data _ Applicant KJICT rn,a11717d%J/1 s, �,s..st�a����[,�
NOTIC T APPLICANT: If, atter making t iz or dm of Exemption, pERI�11U�p 1yuU:N 1p1U St A(H�C_ : ♦��
You should become subject to the Workers' Compensation woviziOps Of the
Labor
be deemed re okee ormwim comply with such provisions or m'Is permit DATE OF APPLICATION
I certify that I have read this application and state that the above informs
tion is correct. I agree to comply with all city and county ordinances and
state laws crating to building construction, and hereby authorize represent l�
tatives of this city to enter upon the above-mentioned property for inspection
Purposes.
(We) agree to save, indemnify and keep harmmss the city of Cupertino PERMIT VALIDATION
against liabilities.judgments costs and expenses which mayin nr y accrue
against said Ci�in col�n�{s,Lq/ts��6 ep/��the�gran ting of this perm /
\� SigneS�A»�nt on2 tractor Data 7
REQUIREDPRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY