R-0205 `f. PERMIT R_ 020[
APPLICATION FOR CITY OF CUPERTINO NUMBER �J j
INSPECTION DIVISION
ON
REROOF PERMIT PERMIT EXPIRES I PERMITE ORKI N
TED
WITH N OF PERMIT
NOTSTARTED
+j+
180 DAYS FROM LASTCALLEDSINSPECTI ON.
:.' BUILDING ADDRESS BUILDING USE
(,(y( lQ 1. RESIDENTIAL4 COMMERCIAL OTHER
OWNER'S
ka+//kN U FIRE COVERING
/,I HAZARDOUS ROOF
NAME�
�A// / AREA CLASS
�- yV .ul{j Mp"G Q,�/ n?' EXISTING ROOF COVERING
ADDRES /—i-�.a� 'lU "`"r"'lll '
PHONF.2 —V / NUMBER OF EXISTING COVERINGS
CONTRA TOR
• TO BE REMOVED�TO BE RETAINED '
NAME_ I�IC I TYPE OF ROOF COVERING
a e t
ADDRESS, III,l Ill�✓Q ll 9SAZ6
CITY&ZIP EXISTING
2
PHONE qc] BUILT-UP ROOF
✓p—E� '
LICENSEC ASPHALT SHINGLES
NUMBER q16J WOOD SHAKES Lliesaxi
L I CENSEO CONTRACTORS DECLARATION
I hereby affirm mal I am licensed under provisions of Cl 9 mommem WOOD SHINGLES
ting with Section 7000) of Division 3 of the Business d PROfossi0ns Code,
ane my upenae in f r rte am euogt. 5
License c sz Lic.Numbs
Date Contractor OTHER (SPECIFY)
WNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the following reason. (Sec. 703 1.5. Business and Professions Code: Any city
Or count, which applies a permit to construct,alter,improve,demolish,or , a
repair any structure,prior to its issuance,also requires the applicant for such BUILT-UP ROOF
permit 10 file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law(Chapter 9 (commencing with Section 7000)
of Division 3 of IM1e Business and Professions Code)or that he is exempt mete ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation Of Section
..} 7031 5 by anymapplicant for a permit subjects the applicant to a civil penalty /
of not more at five hundred dollar:( 500).) : WOOD SHAKES
❑ I,as owner Of the property,Or my employees with wages as fair sole
compensation,will do the work,.and me structure is not intended or offered WOOD SHINGLES
for sale (Sec. 7044, Business and Professions Cade: The Contractor's License
Law does not apply to an owner
of property who builds or improves thereon,
and who does such work himselfor through his Own employees,provided that
bpch Improvements a not intended o offered for sale. If, however, he OTHER (SPECIFY)
uilding o mprovemenl Is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improvelor -
purpose ofsale.). PROVIDE I.C.BaO. REPORT NO.
❑ I, as owner of the property, a exclusively contracting with licensee G
contractors t0 construct the project (Sec. 7044, Business antl Professions
Code: The 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
contractor(sl licensed pursuant to the Contractor's License Law. r
❑ 1 am a—Pt ender Sar. ,B.&P.C.for his FASTENE D
oason wns. Date-
WORKERS-COMPENSATION
ateWORKERS-COMPENSATION DECLARATION V
I hereby affirm that I have a certificate of consent to self insure, TYPE 31 egoC
tificat.Of WorkersCompensation PoJ
ysfsura ca ore certified copy thereof(Sec. �J
3800,La�b'.I/C/1. J
eerrtied pope is _ had. LENGTH
Of
❑ carr tied 1' �- RtAe��v"tr spaction division.
" Applicant " FEE SUMMARY r
CERTIFICATE E EXE N FROM WORKERS' J
Coot be co TI INSURANCE
(This section need not be completed if the permit is for one hu ndrCtl tl01-
hrs($100)or mss.) VALUATION
I certify that in the performance of the work for which his permit is x.
issued, all not employ any parson in any manner 00 as to become subject.
to IM1e Workers'Compensation Lows of Calllornia.
Data Applicant
NOTICE TO APPLICANT: If, after-making thisCertificateof Exemption.
PER FEE
you should become subject to the Workers' Compensation provisions of the t
Labor Code, you must forthwith comply with such provisions of this permit
shall be deemed revoked. / DATE OF APPLICATION
I certify that I have read this application and state that the above informs
tion is correct. I agree t0 comply with all city and county ordinances and /OVOVOV/(J
sxate laws relating to building construction, and hereby authorize represem
tatives or this city to enter upon the above mentioned properly fof inspection
purposes. y PERMI VAL DATION
IWeI agree to indemnif and keep harmless the City of Cupertino
against liabilities mems,costs and expenses which m n enV V
again$ nsepuen of me granting of this pe it, accrue �)
Si gnatore of A plicant/C cctor DatO
REQUIRED RE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS hINSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY