R-0259PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R_ 0
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
BUILDING USE
/
S �/qPQ .tet lOdrol,,, _
RESIDENTIAL COMMERCIAL OTHER
OWNER'S—f
7A.,lP �'r�^'T�g�
HAZARDOUS ROOF
NAME �`
FIRE COVERING
AREA CLASS
EXISTING ROOF COVERING
..
ADDRESS
YS F
NUMBER OF EXISTING COVERINGS
PHONE C�,fS7- ,0
CONTRACTOR'S
�� -
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF. COVERING
NAME (s0/'e0i YNA�O'J
ADDRESS,
CITY & ZIP J5yA
EXISTING
PHONE �S^f? — 3SI.Sr
BUILT-UP ROOF
ASPHALT SHINGLES
LICENSE
��.%j
NUMBER U�
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commem
ing Wim Section 7DDDI of Division 3 of me Business and Professions coda,
WOOD SHINGLES
and my license' ry II force and effect.
63
License as LIc,Number
Date
OTHER (SPECIFY)
Contractor
OWNER BUILDER DECLARATION
,\
Iheraby 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
\`y
orunty which requires a permit t0 construct, alter, improve, demolish,Or
repair 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
t
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of me Business and Professions Coda) 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 subjects the applicant to a civil penalty
of not more mat five hundred dollars (8500).):
WOOD SHAKES
❑ I, as owner of the property, or my employees with wages es their sole
"
com pan sation'will do the work, and the structure is not intended or offered
s
for sale (Sec. 7044, Business and Professions Code: The contractor's License
WOOD SHINGLES
Law does not apply t0 an Owner of property who builds or improves thereon,
and who does such work himself or through his own employees, provided that
ents are not intended o offered for sale. If, however, the
such improvem`
OTHER (SPECIFY)
building or improvement is sold within one Year of c mpletion, the Owner
builder will have the burden of proving that he did not build or improve for
purpese°f sale.).
PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor 'sLicense Law does not apply toanowner ofproperty
PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who contracts for such projects with a
contractors) licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. ,B,&P,e, for this
reaon
FASTENER
C-_ C O
Owsner - Data
WORKERS' COMPENSATION DECLARATION
I hereby that I have a certificate of consent to self. insure, or car.
affirm
['heath of Workms' Compens.u.ne Insurance, Or c tified copy SM1ereof (Sec.
TYPE 41 y
3800, Lab. C.I. N��/ —/ 'Af
Policy No. CornpanY -s /N'� C, s^
Certified copy's hereby furnishes.
^ f LL S
1 /T
^x�Car ti}i/ed/ COpV is filetl Wi111 the city spection division, -
LENGTH.
FEE SUMMARY
" Applicant ETb Aar, 1211�4r"�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred doh
3
Isis (Sloe) or less.)
VALUATION 3 �!
I certify mat he the performance of the work for which this permit Is
issued, I $hall not employ any person in any m er soasto become subject
to Lha Worker' Compensation Laws of Californian
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
PERMIT FEE
You should become subject to the Worker' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions Or this permit
DATE OF APPLICATION
's'shan be deemed rfri
I certify that I nave read this application and state that the above informa
tion is correct. I agree to comply with all city and county ordinances and
p
rucon, and hereby authorize reprised
struche",
-� ate laws relating to building constti
O
p '
tmives of this city to anter upon the above mentioned property for inspection
PERMIT VALIDATION
purposes.
(We) agree to s indemnify and keep harmless the City of Cupertino
against liabilities,clti judgments, , costs and expenses which may in any way accrue
against x City unser, encs of the granting of this permit.
s
Sign ere of Appli t/Contracfar
PRE -INSPECTION
IN-PROCESSINSPECTION
, 'FINAL INSPECTION
REQUIRED
11
INSPECTIONS
INSPECTOR DATE
INSPECTOR DATE_
INSPECTOR DATE _
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR