R-0260If 1 AJ
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 026c�+
9,
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT PERMIT EXPIRES IF WORK IS NOT STARTED
'
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
i
I8o OAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS-
BUILDING USE
�
'Z-0 (CP Z__
CJ
RESIDENTIAL COMMERCIAL OTHER
OWNERS
V aei
HAZARDOUS ROOF
NAME Y y `R"' • p^
FIRE [? COVERING
AREA CLASS
' I
'7`O( �T
-fi s' G. q � (
ADDRESS
EXISTING ROOF COVERING
F�7 �
ZS Z.- a)-("1
NUMBER OF EXISTING COVERINGS
PHONE
I
-
CONTRACTOR'S
AL'S
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
NAME -�^�C--�1�^ Z-- 1\Y.�l' _
I
ADDRESS, L. Vt
,�
CITY &ZIP (��jj3 �'-�I � L ` �
EXISTING
��Q
�G�G�
?*G(0 • IS(4)1 Q
BUILT-UP ROOF
PHONE y'��
ASPHALT SHINGLES SEP
LICENSE
43 Z'�� L
NUMBER
WOOD SHAKES. - 'QlyOf
LICENSED CONTRACTORS DECLARATION
IIGM!/s0
I hereby affirm that I am licensed under provisions of Chapter 9 (comment
Clog with Section 7000) of Division 3 of the Business and Professions Code,
WOOD SHINGLES
end my license is iryfal and affect. 443Z.170 I
C Se "I 3 Zai 7�
'
License Class Lic. Number
Date S • f —AS Contractor
OTHER OTHER (SPECIFY)
OWNER -BUILDER DECLARATION
Ihatch, affirm ma,.l am exempt from the Contractors License Law for
PROPOSED
the following res (Sec. 7031.5, Business and Professions Code: Any city
-'
county whichAT, a ices a permit to c nstruct, alter, improvem
, deolish,or
repair
any structure, prior to Its issuance, also requires the applicant for such
BU LT -UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
01 the Contractor'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 me alleged exemption. Any violation of Section
'
]031.5 by any, applicant fore permit zu phi the applicant [o a civil penalty
of not more that five hundred dollars ($500).b
WOOD SHAKES
❑ I, aser of the property, ormy employees with wages as their sole
com pensation, will do the work, andme s[ructu re is not intended o offered
for sale (Sec. 7044, Business and Professions Code: The Contractor's License
WOOD SHINGLES
Law does not apply to an owner of property who builds or improves thereon,
and who does such work himself or through his own employees, provided that
such improvements are not intended o offered for sale. It, however, the
OTHER (SPECIFY)
building o improvement is sold within one year of completion, the owner
builder will ave the burden of proving that he did not build Or improve for
purpose sale.).
PROVIDE I.C.B.O. REPORT NO.
1 me propene, a exclusively Contractingwith
❑ J.
feensed
st
contractors m construct Ne project (Sec. ]044, Business and Professions
Businss
The
Cade: The Contractor's License Law does not apply to an owner of property
PROVIDE MFGR. INSTALLATION SPECS.
who or mproves thereon, and who contracts for such projects with a
contractor (s) licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. ,B.&P.C. for this
reason
FASTENER
Owner Data
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have certificate of consent to self. insure, o
Wor
TYPE S`
silicate of kari Compeen Insurance, 1r a Carl Copythereof (Sec.
3800, Labs CAls paw
/C'ti-
oTcyTalp C p nv 5�,�,•`L �V
C sf)ed cony is hereby w shed. ,
LENGTH
tiflgd cop�il(etl—whh jfl inspecti on division.
ry
FEE SUMMARY
A nt {M
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dub
late ($ t 00) or mss.)
VALUATION Zs oto,
I certify that in the performance of the work for which this permit is
issued, I shall not employ any person in any manner s° as to become Subject
to [M1e Workers' Compensation Laws of California.
Dot° Applicant
NOTICE TO APPLICANT: Ii, after making this Certificate of Exemption,
PERMIT FEE ���
you should become subject to the Workers' Compensation provisions of the
'het o deemed revoked forthwith comply with such provisions or this permit
OF
DATE APPLICATION
I certify that I have read this application and state that the above informs
tion is correcagree to comply with all city and county ordinances and
state lawsrola ting to and hereby authorize
^ .•) A
sp Chun
talipes this city to enter upon the above mentioned property for Inspection
ntbuilding n the above
PERMIT VALIDATION '
purposes.
s,
We) agree to save, indemnify and keep harmless the City of Cupertino
l
against'siabi Cities, judgments, cons and expenses which may in any way accrue
against said city, iAn_consequence of me y.antine of this permit.
IA -1 AL/Ii(.a CS—
Signature Of Applicant/Contractor Data
PRE -INSPECTION
IN -PROCESS INSPECT ION
FINAL INSPECTION
REQUIRED
h
INSPECTIONS
INSPECTOR DATE
INSPECTOR DATE
INSPECEOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY