R-0196 i
PERMIT R-
APPLICATION 96
APPLICATION FOR CITY OF CUPERTINO NUMBER 97
REROOF PERMIT INSPECTION DIVISION PERMIT GXPI RATION
EXPIRES IF WORK IS NOT STARTED
WITHIN180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
Q 31 SISk7'EhB,ER CT
/l/-,QAil,a C'44-1"'i- RESIDENTIAL COMMERCIAL OTHER
OWNER'S
,O A/� HAZARDOUS PFJES ROOF
?
NAME AI ��X ENB/q UI�J FIRE kit Apiki CLOVES ING
AHEADDRESS V 31 5FP��.tiBr-/2 Cell EXISTING ROOF COVERING
C uPC—RiZNa CA4•1F Cf Q I
PHONE CJ/ l� vE 996 - X56 NUMBER OF EXISTING COVERINGS
CONTR —
ACT R'S
70 BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADDRESS,
CITY&ZIP EXISTING
BUILT-UP ROOF
PHONE
LICENSE ASPHALT SHINGLES -
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(comment ter/
.In. with Section 7000) of Division 3 of the Business and Professions Code, WOOD SHINGLES
and my license is in full force ane effect. -
License Class Lic.Number
Date Contractor OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors 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, demolizh,Or t _
ophr env svucmre, prior to its issuance, also requires the applicant forsuch BUILT-UP ROOF (
Fermi( to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) s `/
of Division 3 of the Business and Professions Code)or that he I$exempt mere ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permitubjects the applicant to a civil penalty
of o are that flys hundred dollars L$500). ): WOOD SHAKES
C.; I, as owner Of the property, or my employees with wages as their sole
rNponsuti on,will do tha work, and the structure is not intended or offered WOOD SHINGLES
for sale (Secr
. ]044, Business and Professions Code: The Contractor's Ln
icese
Law does net apply t0 an Owner of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that
such improvements are not intended or offered for sale. It, however, the OTHER (SPECIFY) -
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
•.❑ 1, as owner st me property, t i excessively cmness a with licensed
contractors to construct the project ISe<. 7044, Business and Professions .
ods: The Contractors License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or mproves thereon, and who contracts for such projects with a
contractor(s)licensed pursuant to the Contractor's License Law.
O 1 am cramp, under Sec. ,B.&P.C.for this
reason FASTENER
Data
WORKERS COMPENSATIONLARATI ON ('� / ^ ' ^ I f n
I horaby affirm that 1 have a certificate of consent to self-insure,or a car. ^ TYPE R�xir IAl V ,V ,J L J
Slf lco to of Workers' Compensation Insurance,or a certified copy thereof(Sec.
3800, Lab.C.).
Policy No. Company
Certified Cop,is hereby furnished. - LENGTH .
Certified copy is filed with the city Inspection division.
Applicant
FEE SUMMARY
CERTIFICATE E EXEMPTION FROM WORKERS'
COMPENSATION SATION INSURANCE /
(This($ Section head not be completed it the permit is for one hundred d01 ^O�
(ars(cdIgf or I at i VALUATION
1 certify that in the performance of the work for which this permit is
Lied, I shall not empty any Lenon in any manner so as to become subject • �1
0 rho Workers Compensation Laws of Colilbrnia. /5 /
Oats Applicant //'
NOTICE TO APPLICANT: If, atter making this Certificate of Exemption. PERMIT FEE 5� ~—
You should became subject to the Workers Compensation provisions of the
Labor Code,you must forthwith comply with such provisions or this permit I
hall bedeamad reyoked. DATE OF APPLICATION
I certify that 1 have read this application and state that the above informs
tion is correct. agree
to comply with all City and county Ordinances and
state laws relating to building construction, and-hereby authorize represent
relives of this city to enter upon the above mentioned property for inspection
Purposes.
(We) agree to sever indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against liabilities, judgments,costs and expenses which may in any way accrue
g . t said City .nseque ce of the granting of this permit
l�Igni tura of AFLI cant/Contractor Data
REQUIREDh ' -PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE h INSPECTOR DATE h INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO.ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY