R-0243PERMIT R- OZ43,'
CITY OF CUPERTINO NUMBER
APPLICATION.FOR
INSPECTION DIVISION
PERMIT IF WORK NOT STARTED
REROOF PERMITPERMSTE ORKI N
180DAEXPIRES
DAYS OF PERMIT ISSUANCE OR
I
WITHIN80
S F
I80 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
t'
1
RESIDENTIAL !!i COMMERCIAL OTHER
OWNER'S
{�
HAZARDOUS ROOF
NAME 1. ) ( X17`11l_
FIRE COVERING
AREA CLASS
EXISTING ROOF COVERING
ADDRESS 1011 �:CrmaDOOTH,i
NUMBER OF EXISTING COVERINGS
PHONE
CONTRA TO R'S
n (-
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
NAME Qr4 ���(1�1 l P_ Vn 4if`C)�
ADDRESS , 0
CITY l ZIP II
EXISTING
1
BUILT-UP ROOF
PHONE91o�(01
ASPHALT SHINGLES �lf�
LICENSE
NUMBER
WOOD SHAKES MPC\ulo. r�,jii
LICENSED CONTRACTORS DECLARATION
I hereby affirm =hat I am licensed under provisions of Chapter g (commen-
zing with Section 7000) of Division 3 of the Business and Professions Code,
-
WOOD SHINGLES
and my license is in full force and effect.
CI
-
License Class C—'Ay Liz. Number ?7iZ L1 (�
'
OTHER (SPECIFY)
oat. 9131 2S: contractor koc
OWNER -BUILDER DECLARATION
1 hereby affirm that exempt from the Contractor's License Law for
PROPOSED
the following reason. (Sec. Business and Professions Code: Any city
iowir .
county which permit to construct, alter, improve, tlemoliaM1,Or
req prior a cps
t ora, prior to its ithat ee also re irescur the applicant for such
re issuance,
repair any structure,
BUILT-UP ROOF
signed sed
Permit to file a statement that he is licensed to the provisions
t Li (commencing with Section
of the Contractor's License Low (Chapter (commencing .•
t7000)
Division 3 of the eprmesr and Professions coda) or that he k exempt here
s
ASPHALT SHINGLES
coon
from and the basis for the allegetl exemption. Any violation of Section
from m
70315 by any applicant fora parmi[ s.bjetta the applicant t0 a civil penalty
of not more that five hundred dollars 1SBB13j.).
WOOD SHAKES
❑ I, as owner of the property, or my employees with wages as their sole
cc .ansation, will do the work, and the structure is not Intended or offered
for rale (Sec. 7044, Business and Professions Code: The Contractor's License
WOOD SHINGLES
Law does not apply to on owner of property who builds or improves thereon,
and who does such work himself or through his own employees, provided that
t pch Improvements a not intended o offered for sale. Il, however, the
OTHER (SPECIFY)
building o improvement is sold within one year of completin, the owner
builder will have the burden of proving that he did not build or improve for
1
purpose of sale.).
PROVIDE I.C:,B.O. REPORT NO.
❑ I, a of the property, a xclusively contracting with licensed
contractors to construct the project (Sec, 7044, Business and Professions
coda: 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(s) licensed pursuant to the Convacmr's License Law,
❑ 1 am exempt under Sec. ,B.d P.C. for this
- FASTENER
owner Data
WORKERSCOMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a car
a
TYPE .
tificate of Workers' Compensation Insurance, or certified copy thereof (Sec,
`•,
•r
y
3800, Lab. C.1.
—11
Policy No.7CIA g 2 ll% Company Ale V. ezaf!
❑ Certified copy is hereby furnished.1
LENGTH -
Bixi hied copy s Rled with me <ity:mspacson division
FEE SUMMARY
Applicant
CERTIFICATE OF EXEMPTION OM WORKERS•
'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol-
lars IS1000 or less.)VALUATION
PI—S
I certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner so as to become subject
10 the Workers' Compensation Laws of California.
Date - Applicant
NOTICE TO APPLICANT: If, after making this certificate of Exemptlo"'
PERMIT FEE
You should become subject to the Workers' Compensation provisions of the
_ use
Labor Code, you must forthwith comply with such provisions or this permit
-
DATE OF APPLICATION
She be reamed revoked.
I certify that I have rear this application and state that the above informs
tion is correct. I agree t0 comply with all city and county ordinances and
/
state laws relating to building construction, and hereby authorize represen-
tatives of this city to enter upon the above-mentioned property for inspection
PERMIT VALIDATION
purposes.
(we) agree to save, indemnify and keep harmless the City of Cupertino
against liabilities cense costs and expenses which may in any way accrue
against said City in consequence o1 the granting of this permit.
/1
} n - `11 31 P,�
7 '
Signature of Applicant/Contractor Data
PRE -INSPECTION
IN -PROCESS INSPECTION
FINAL INSPECTION
REQUIRED
INSPECTIONS
INSPECTOR DATE_
INSPECTOR DATE_
INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR