R-0200 PERMIT R_ 0200
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
46 t WITHIN 180 DAYS OF PERMIT ISSUANCE OR
_ 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
"T'► li O kK, . rnA��wDO w cOO R RESIDENTIAL COMMERCIAL OTHER
OWNER'S
M,1/E 1 , 1�p \/ LIP
HAZARDOUS ROOF
NAME K �A/ INV, L_ Y - FIRE COVERING
AREA Fizi CLASS
ADDRESS -1� 921l ( AK mIL: KP AI C.OoRT EXISTING ROOF COVERING
PHONE �� Loa — ' 0 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ' • , / p"A�, , `7—
NAMEI'ISW� t W ' LU(TIV�� � N\FVIOR TO BE REMOVED EO TO BE RETAINED
TYPE OF ROOF COVERING
P pt If 1
CDDF$Z1 � $H 01 LAS• Q j JM Rf.>r= S Z EXISTING
ws 6 A TaaS ? C R 11503 0
PHONEST S � g BUILT-UP ROOF
LICENSE -1 3/ / I ASPHALT SHINGLES
NUMBER _1 l0 I `1
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I of licensed under provisions of Chapter s ons(common ✓ '
eine wean ane is I Tooth of Division 3 of me Business and Professions coda. WOOD SHINGLES
nd my license is in II,nice and effect.
License
CI ss Lia Number
Data Contractor�Lllfl $ OTHER (SPECIFY)
O ER-BUILDER DECLARATION
1hereby affirm that 1 am exempt from the Contractor's License Law for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
linty which requires a permit to construct, alter, improve, demolish,or
repair any znunwe, prior to is issuance,also requires lnaapplicant for such BUILT-UP ROOF
permi' to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 1000)
!'< 0f Division 3 of the Business and Professions Code)or that he is exempt mere ASPHALT SHINGLES
p 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 more that five hundred dollars(85001.): WOOD SHAKES
❑ I,as O of the property, or,my employees with wages as their ou
mpohisabo�will do ma work, and e structure Is not intended or offered WOOD SHINGLES t�
for sale (Sec. ]044, Business and Professions Code: The Contractor's License
~, Law does not apply l0 an Owner of properly 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 sate. If, however, me OTHER (SPECIFY)
building or improvementsold within one year of completion, the owner
builder will have the burden of proving that he did not build or Improve for
purpose 1, at:o sale.).
PROVIDE I.C.B.O. REPORT NO.
❑ I, r st ma pe project
a exclusively contracting with licensee
C rid.: inn m construct the Profen does. t app Business and Professions property Code: The or improves
License
and doeswho cot tracts for
an owner projects
is with a PROVIDE MFGR. INSTALLATION SPECS.
who builds or Improvessuantthereon, end who aOnnacrs en such nroiecv with a
contract am licensed pursuant to ma Contractor's License Law.
❑ lame exempt antler sec. ,B.aP.c.for this
reason FASTENER
Owner Date �
WORKERS'COMPENSATION DECLARATION �^
hereby affirm that I have a certificate of consent to self insure,o — TYPE N \l
tifica'a Of Workers'Compensation Insurance,Or ancertified copy thereof(Sec. '
Polio, Lab.Cz In SS STATE �,—
POemy Ce Com furnis
❑
Certified copy is hereby wr had. LENGTH
❑ Car'ified copy is filoq y.m the c'ty inipoctiOn 11iv'
Applicenc��W1 OC�b1 �FZb�f..��,I
CE TIFICAT OF(EXEMPTION FTOM WORKERS' 'FEE SUMMARY
COMPENSATI O NINSURANCE Z
(This section need not be completed if the permit is for one hundred dol
Ill($too)or that
i VALUATION
certify [not in me performance person Of the work for as lob co a permit is \
to'he, onkel not employ any Person in any manner so as to become subtest `
to the Workers'Compensation Laws of California.n
Date Applicant
NOTICE TO APPLICANT: o after making this Certificate of Exna ofion, PERMIT FEE T —� .�E-75�'7 1C
you should become subject l One Workers'h such
provisions
provisions a me
Labor
be eoamea.e.redmrmwiln 1,mply with Sueh provisions or this permit DATE OF APPLICATION
I certify-that I have read this application and state that the above informs. t
tion is correct. I agree to comply with all city and county Ordinances and
stalk laws relating to building construction, and hereby authorize represent '
'olives of this city to enter upon the above-mentioned property for inspection
purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against liabilities,judgments,costs and expenses which may in any way accrue
f against said City in consequence of the granting of tCis'pkrmit.
•K. r Eligirlature of Ap tNAV pntreclor Dino
REQUIRED I
PRE-INIPPECTION 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