R-0127 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 0127
- ' INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
i � 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
76 s9 024,iI Vol ,1 &Z RESIDENTIAL "riCOMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF I
NAME2 N N FIRE COVERING
n J ��cc.. AREA CLASS
ADDRESS .4211��f ? EXISTING ROOF COVERING
PHONE a 5 3 - NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
� � TO BE REMOVED / TO BE RETAINED
NAME koala P14 s,� 2-.� ...�M TYPE OF ROOF COVERING .
ADDRESS, y -3 &C) �7� �o (/,,i EXISTING
CITY & ZIP )
PHONE
3 - BUILT-UP ROOF III
LICENSE
ASPHALT SHINGLES
NUMBER x 6-3 -7 7 � I
cJ / WOOD SHAKES f� �
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(Common
aing with Section 7000) of Division 3 of the Business and Professions code, WOOD SHINGLES
nd my Ik:,n.4n lull for tl elfect. - Z
License cI1- . Lic.Number S3 OTHER (SPECIFY)
Date Z— -4i Con,,acl.r
OWNER-BUILDER DECLARATION
I hereby affirm mot I am exempt from the convectors License Law for PROPOSED
the following re , (Sec. ]031.5, Bu Sloss and Professions Cade: Any city
Linty Whichrequi res a permit t0 C nstruct, alter, improve, demolish,or
repair any Structure,prior to its issuance,also requires maapprcant forsuchBUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
.� of the Contractors 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
_ 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 penally
of not more that five hundred dollars(S500).1: WOOD SHAKES d•'x�
E] 1,aof the property, 0 my amWith wages as heir solo
11 en pensatiorwwiranti
do me work, andthe structure i5 not Intended or offeree WOOD SHINGLES
for sale (Sec. 7064, Business and Professions Code: The Contractor's License
Law does not apply toe of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that
Lich Improvements are not intended .roffered for sale. If, however, he OTHER (SPECIFY)
building O improvement is sold within one year of c mpletio n, me Owner
builder will have the burden of proving that'he did not build or improve for
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sac. 7044, Business and Professions
Cper: The ContractorsLicense Law does not apply toanowner ofproperly PROVIDE MFGR. INSTALLATION SPECS.
who UPI Ids or Improves thereon,and who contracts for such projects with a
contract.r(z) licensed pursuant to.the Contractor's License Law.
❑ 1 am exempt under Sec. ,B.&P.C.for mit FASTENER
ezon
Owner Date
f WORKERS-COMPENSATION DECLARATION
I I hereby affirm that 1 have a certificate of consent to seR.insure,or a at. TYPE
,film,. of Workers Compensation Insurance,or a certified copy thereof(Sec.
3800, Lab.Cd. - y
Policy No. Company
gcandied Copy is hereby furnished' LENGTH �2 — 2
Ce titled copy is tiled with the City inspection div,
gppl1Cent FEE SUMMARY
CERTIFICATE E EXEMPTION FROM WORKERS'
COMPENSATION S millet EXEMPTION
the
NCE
perm
(This section neetl not be completed it the permit is for one hundred doh
pars Till Cutlass.) - VALUATION
certlty that in ,h. performan Co of thew in for,,rrllwhich this permit is '{
issued, I shall Ot.,of., any person n¢!Spar 3S[e be[.mQ sub)OCt tj
to mo or ���oa���y��r'S selion Lews lif lin,. /((/
10 Applicant _
NOTICE TO APPLICANT: If, alter ekpig�t�Certificate of ExempR.n, PERMIT FEE .� 'V t��i-S�rfiC S7l
you should become subject to the Workers Compensation provisions of the �-
Labor Code,you must forthwith comply with such provisions Or this permit
shall be deemed revoked. DATE OF APPLICATION
I certify that I have read this application and state that the above s
inform `q
no it correct. agree t. Comply With all Illy and county Ordinencaz and
state laws relating to building construction, and hereby authorize represOm J
On
Iva,of his city to enter upon the above mentioned property for inspection
purpose
(We) agree r v per PERMIT VALIDATION
(We) to s indemnify end keep harmless the Cit Ot Cupertino
against II sung nts,Costs and expenses which may In any way accrue
again in cya equen<e of the granting Of This permit. _/—5-
9al
f`
Sign re of ApPl,.cant/Contractor Data
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