R-0238 i
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 0238
REROOF PERMIT INSPECTION DIVISION EXP'
EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
941,5—
( Q Lf RESIDENTIAL COMMERCIAL OTHER
OWNER'S
' HAZARDOUS ROOF
I
NAME �LJQr' SC1001 Pill V\ FIRE COVERING
j� n AREA CLASS
ADDRESS �7S �YJDU 'e hn .GJ-C V' Dr \. Ocri,ICJ EXISTING ROOF COVERING
PHONE oCn3 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
f TO BE REMOVED TO BE RETAINED
NAME I k6 d Me4yN O 1 TYPE OF ROOF COVERING
ADDRES
n r
CITY&ZSF V EXISTING
_ —�'� BUILT-UP ROOF
PHO E
LICENSEa> O3 ASPHALT SHINGLES
NUMBER
WOOD SHAKES
Lm that
CONTRALTOr DECLARATION
hereby affirm Inst of licensed under provisions of Chapters ons code,
ting with section 7000) of Division 3 of the Business and Professions code, WOOD SHINGLES
antl my hcanse y{n[ e and effect.
License Clad ` Lic.Numbs
Date_ convaaor vq.OTHER (SPECIFY)
III�OWNER-BUILDER from
the C ION Cl
hereby affirm that f . exempt from s a Convector's License Low for PROPOSED
the following is (Sec. permit, Business and Professions Code: Any h,.,
Linty which a permit to construct, alter, improve, demolisM1,or
erpi any structure, prior to its issuance rise requires the Applicant for such BUILT-UP ROOF
permit co file a signed statement That he is licensed pursuant to the provisions
0f the Contractor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Professions Code)or that he is exempt there ASPHALT SHINGLES
r
fir and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects me applicant to a civil penalty WOOD SHAKES
� - of no,more that five hundred dollars($500).):
D I, es Owner Of the property, o my employees with wages as brir sole 7
lamppnsa hon.will do the work, and the structure is not intended o offered
r sale (Sec. 7044, Business and Professions Code: The Contractors License WOOD SHINGLES
Law does not apply to an Owner of property who builds or improves thereon,
and who does such work himself Or through his own employees,provided that
such improvements are not intended or offered for sale. If, however, he OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he die not build or improve for
Purpose of sere.). PROVIDE I.C.B.O. REPORT NO.
I, as Owner st the heProperty,project
a exclusively Business contractan with licensed ssions
con vectors to construct the protect (Sec. 7044, Business and Professions
oda: The Contractor's License Law does not apply to a owner of property PROVIDE MFGR. INSTALLATION SPECS.
who In Or improves thereon, and who contracts for such projects with a
contractor(s)licensed pursuant to the Contractor's License Law,
0 1 am exempt under Sec ,B.&P.0 for this
reason FASTENER
Owner Data
WORKERS'COMPENSATION DECLARATION
I hereby affirm That I have a certificate of consent to amf.insure,Place,
TYPE
hdicate of Workers' Compensation Insurance,or a certified copy thereof(Sec.
3800, Lob.Cd.
Policy No. Company
® Cernned copy is herebvfgrnished, LENGTH
COrtili ed copy iz filed with the city inspection division.
Applicant FEE SUMMARY
CERTIFICATE E EXEMPTION FROM WORKERS'
COMPENSATION completed
INSURANCE N
(($'0 )or In need not be cOmpletee it IM1e permit is for one hundred doh
Iers(sero)er lee,.) VALUATIOP4i SSS
certify that in the performance O1 IM1e work for as to I Or permit is
issued, 1 shall I employ any per any manner ;esJO,bncotn Lib
to mo VV o kers' Pensation Law of DaIH `x,I~VA/'//LL �I
Do Pool.' '1
NOTIC TO A I ANT: Ii, af>T: akin rbfinete of Exemption, ro
you should become subject to the Wo ' soften provi Of the PERMIT FEE '7G7�J— S6/J'r-j e w
dol bCode
duan d re must forthwith comply with open provision:or this perms DATE OF APPLICATION
s I certify the, I have read this application and state that the above informs- -
,ion is correct. agree t0 Comply with all City and county Ordimmc.s and
stat. laws relating to building construction, and hereby authorize represen-
tatives of this city t0 enter upon the above-mentioned property for inspection
purpOSes.
(We) agree tp say.,
ay indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against liabilities,judgments,casts and expenses which may in any way accrue
against said City in cons qua a of the granting of[hisser
netur rA I-
en UContractor Da
r>_
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
INSPECTOR COPY