R-0173 l„ I
PERMIT R- 0173
APPLICATION FOR CITY OF CUPERTINO (� - NUMBER
REROOF PERMIT ' INSPECTION DIVISION �J PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
s«i WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
a 50 Arc T RESIDENTIAL COMMERCIAL OTHER
OW ER'S
NAME x/19�� HAZARDOUS ROOF
/ J /S {9C1� PZ// FIRE COVERING
�– AREA CLASS
ADDRESS /Oil eloiVIII A71—C, EXISTING ROOF COVERING
PHONE \ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
_ /y� TO BE REMOVED TO BE RETAINED
NAME �A/f5T l O/d57 �� n/6 / //li/NE( IN/�IL�✓ TYPE OF ROOF COVERING
ADDRESS,
_ CITY&Z/IP�L�y�S7 -C71pNNA ( i - �i <MOU i ft/S3�i EXISTING .
- PHONE
BUILT-UP ROOF
LICENSES �.7p ASPHALT SHINGLES r
NUMBER J/
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(common- WOOD SHINGLES
eIng With Section 7000) of Division 3 of the Business and Professions Code,
nd my license i I force and etfec t. '�'I
License Imz Lic.Number AilY.
Dote , -/s - Contractory ✓/I—Ji OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exam of from the contractors License Law for ,PROPOSED
the following rei (Sec. 7031.5, Business and Professions CAIe: Any city
recounty whichrequires a permit to construct, alter, improve, dem Olisll,or
pair any structure, prior to its issuance,also requires the applicant for such BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
�- of the Contractor's License Law (Chapter 9 (commencing with Section7000)
f 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 or Section
.{/ 7031.5 by eny,applicen[ for a permit subjects the applicant to a civil penalty
of net more met five hundred dollar:($500).): WOOD SHAKESy
L3 1.as owner of the property,or my employees with wages as their sole
compensation.will do the work,and the structure is not intended or offered WOOD SHINGLES
fpr sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply to an owner of property who builds Or improves[hereon,
and who does such work himself or through his Own employees,provided that
such improvements aro not intended or offered for sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
builder will have[M1e burden of proving that he did not build or improve for
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: Th a Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who contracts for such projects with a -
contractors) pursuant to the Contractor's License Law.
❑ I am exempt under Sec. ,B.aP.e.for this FASTENER
:son
Owner Dafe
WORKERS'COMPENSATION DECLARATION
1 hereby affirm first I have a certificate of consent to self insure,or a car- TYPE
tlflcate of Workers' Compensation Insurance,or acertified copy thereof(Be..
3800, Lab.C,).
Policy No. Company If
oCertified cop,is hereby Iumishad.
Certified copy is filed with the city inspection division. LENGTH ;at
Applicant FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dol- �r
Isis($100)or loss.) VALUATION 3J �0 s ;
I certify that In the performance of the work for which this permit Is
issued, I shell not employ any perso nV 9 yes tp be subject
I o the orkan'Cpplpensa[ion Lawsi1��`
Data?" Applicant
N
Of ICE�CANT: If, error making this Certificate of Exemption, FEE - •'�' rte' -
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions Or this permit s ,
shelf be overhaul revoked. DATE OF APPLICATION -
certify the[,I'have read orshis ly with al and state that the above aces and
tion is correct. g to
to comply with all city and county authorize
ordinances reps and
state lows relating to building construction, and ne pr aerty rise inspection
do refund of this city m on tar upon theabove mentioned property for inspection
purposes. y PERMIT VALIDATION
(We) Brea s. save, indemnify and keep harmless the City of Cupertino
against liabili es.IudBmen ts,costs and expenses which they' y ay accrue
age I said It cc quen f the granting of this permit. c
���/�`� Data SiBnetu of Applicant/Contractor Date
I ef REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE h INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY