R-0257PERMIT
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APPLICATION FOR CITY OF CUPERTINO 02 J 11
INSPECTION DIVISION PERMIT E ORKI N
REROOF PERMIT PERMIT EXPIRES I F WORK IS NOT STARTED
WITHIN 180 Y PERMIT
SFRAYSOF
INSPECTION
180 GAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING
BUILDING USE
RESIDENTIAL -)(—COMMERCIAL OTHER
OWNER'S
u 1 \
HAZARDOUS ROOF
1 C' Yl
NAME l \eA M Q' l _
FIRE COVERING
AREA CLASS
EXISTING ROOF COVERI G
y`
ADDRESS I b S(2 �d N LCGY%A ro 0.L>Q
r
NUMBER OF EXISTING COVERINGS
L ,"I O
PHONE
CONTRACTOR'S
n �+
TO BE REMOVED_ TO BE RETAINED
NAME TaY,A6K (naI I I 1\0DF 11nG
TYPE OF ROOF COVERING
Gr
ADDRESS 1 _
,^may l `JC� � -� SaT 95133
CITU & ZIP LCJI A'D ^ wAfc
EXISTING
�`
((
I S
BUILT-UP ROOF
PHONE l 9) 9Q'51—SFI
ASPHALT SHINGLES
LICENSE y{
�X
NUMBER C�-3
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
hereby licensed Chapter 9 (commend
attirm that am under provisions of
WOOD SHINGLES
with Section 7000) of Division 3 of the Business and Professions Code,
eing
nd my license is in jylLtorce and affect.
ze ySB32
License Class 'R/ Lia Numbs ,
OTHER (SP
Do,. 9/s/ray Contractor �ins�
'I
OWNER -BUILDER DECLARATION OO
' 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
which requires a permit to construct. alter, improve, dem Olish,or
recounty
pair any structure, prior to its Issuance, also requires theapplicant for such
BUILT-UP ROOF
permi, to hle 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 vioeti an of Section
7031.5 by anyapplicant for a permit subjects the applicant to a civil penalty
of not more that bve hundred dollars (S500).):
WOOD SHAKES
❑ 1, as Owner of the property, or my employees with wages as their sole
compensation , will do 'he work, and the structure,s not intended or offered
tar sale (Sec. 7044, Business and Professions Code:The Contractor's License
WOOD SHINGLES
Law does not apply to an owner of property who builds or improves thereon,
and who does such work himself or through his own employeesprovided that
,uch
__ 11 ,_, T
improvements are not intended or offered for sale. If, however, the
OTHER (SPECIFY) C—or � 11 e
building or improvemen,-is sold within one year of completion. the 0
builder will have the burden -of proving that he did not build or improve for
purpose of aale.).
PROVIDE I.C.B.O. REPORT NO.
❑ 1of the property, am exclusively contracting with licensed
ontrac,„ors to construct the project (Sec. 7044, Business and Professions
Code: ThaContractor 'zLicense 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 ..minor under Sec. ,B.aP.e. for this.
eas0n
FASTENER
Owner Date
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to selfinsure, or a car.TYPE
tifleate of Workers' Compensation Insurance, or a certified copy thereof (Sec.
3800, Lab
La
.3 5+.Ofe r"V� 1
Polley 99 Company. Y C7
.
Cert it led c p9 is hereby fw M1ed.
LENGTH
Certitied is fil with city Prl n division .
I FEE SUMMARY
' App"qa"t
CERVFICATE OF EXEMPTION FROM WORKERS'
fit
COMPENSATION INSURANCE
(This seed n need not be completed if the permit is for One hundred ddol-
lars (sloe) or 1ess.i
VALUATION
certify [M1at in [h0 performance of the work for which this permit is
ued, not employ any person in any manner so as to became subject
WozM1all
to the 'k. s, Compensation Laws of California.
,
DaleApplicant
TO Certificate Exemption,
L'�' S'�/l/`9
NOTICE APPLICANT: after making this of
you should become subject o the Workers' Compensation provisionscions of mo
PERMIT FEE (Do
Labor Code, you moil forthwith comply with such provisions OI this permit
DATE OF APPLICATION
Shan bedeemed revoked.
I certify that: have read this application and state that the above Informa.
aeras [o Comply with
tion is end all city and county ordinances and
lawsws to building construction,abovand hereby authorize
a
state relating
/
sp diem
talipes Uf this city to enter upon me above property for inspection
enter
PERMIT VALIDATION
purposes.
Iwel agree [ indemnify and keep harmless me City of Cupertino
against liabi' idS, judBmenls, cosh and expert 'pb sly in any way accrue
against s Ci in co sequenc f me g gsaw o mit.
I
5.161
K
Signa o Applicant/Co actor Datef
PRE -INSPECTION
IN -PROCESS INSPECTION
- FINAL INSPECTION
RE UIRED
INSPECTIONS
INSPECTOR DATE
INSPECTOR DATE
INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY