R-0231 -!. . ... _ OIS._� PERMIT
APPLICATION FOR f ( CITY OF CUPERTINO NUMBER R- 0231 I
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT ' PERMIT EXPIRES IF WORK IS NOT STARTED
x., WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED NEP.T,ON.
•! BUILDING ADDRESS BUILDING USE
7802 Orlon Lane RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME MaryAnn Rahrork FIRE COVERING
AREA CLASS
ADDRESS 7809 Orion bang EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS one
PHONE
CONTRAC 'S
TO BE REMOVED TO BE RETAINED
NAME Cal-Pac Roofing TYPE OF ROOF COVERING
ADDRESS. 44221 S. Grimmer Blvd. Fremont 94538 EXISTING
CITY & ZIP
PHONE 415/651-3371 BUILT-LIP ROOF x
LICENSE ASPHALT SHINGLES
NUMBER 379503 - -
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 Fit mmen" s
aIng with Section 7000) of Division 3 of the Business and Professions Code, WOOD SHINGLES
nd my license 'n full force antl effect.
License Ciazz Lic.Number
Data Cpnbs OTHER (SPECIFY)
" -BUILDER Deft �•�
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
or county which requires a permit to construct, alter, improve, demolish,or
repair any structure, prior to its issuance also requires the applicant for such BUI LT-UP ROOF
permit to filo a signed statement that he is licensed pursuant to the provisions
..'- of the Convector's License Law (Chapter 9 (commencing with Section 7000)
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 of Section
7031.5 by any applicant for a Permit ubletts the applicant to a civil penalty
of not more that five hundred dopers(8500).)' WOOD SHAKES -
❑ I, If!
owner of the property, or my employees with wages as their sole
m
copensation,will do the work, and the structure is not intended or offered
for sale (Sec. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
Low 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 ler sale. I1, however, the OTHER (SPECIFY) Decra Tile
building orimprovement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
purpoeeos alsiown PROVIDE I.C.B.O. REPORT NO.
❑ I, a of m° property, a xcluzively contracting with licensed3409
contractorsto construct the project (Sec. 7044, Business and Professions
Code: ThaContractor'sLicense Law does not apply toanowner ofProperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or mproves thereon,and who contracts for such projects with a
contracmr(sl licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec. ,B.&P.C.for this FASTENER
Ovine, — Data-
WORKERS-COMPENSATION
ateWORKERS-COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to sell insure,or a at TYPE
Woo
o1 Workers' Compensation Insurance,or a certified copy thereof ISec.
3800, L1
Inc
Policy PbNerA .. 'uhnpany a,.—
p cen� led c pr�s by furnish LENGTH
q CgctJsyt�i 'rd Wh t ry'IM1s�aciion d is'on.
Appl''`_f._. /A1 ayf `FICN FRSAMW FEE SUMMARY
TIFICAT e F EXEMPTION FROM WORKERS'
CO Pbe S millet INSURANCE
(This )orless.)section n¢¢tl nOt be completed if me permit is for One hundred d.1-
are(S100) that
i VALUATION .51600_00
certify tM1at in mo performance of the work for subto this permit is
issued,Workers'not employ any parson in any manner so as to become subject
r to the Workarz'Compensation Laws of California.
Applicant
NOT AE. -pt
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption' PERMIT FEE
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 1 have read this application and state that the above informa. ry
tion is correct. I agree to comply with all city and county ordinances and ,f ^�
state laws relating to builtling construction, and hereby authorize represent (/ � Of
latives of his city to enter upon theabovementioned property for inspection
purposes.
(We) agree to s indemnify and keep hermlesa he City of Cupertino PERMIT VALIDATION
against liabilities,judgments,costs and expenses which may in any way accrue
aeai t be y.: cons o o he granting of this permit.
�- S' eture of pplicant/Co en ctor Date —'� ^•�. y
QUIRED PRE-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