R-0180 PERMIT R_ O 18U
APPLICATION FOR CITY OF CUPERTINO NUMBER v
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT PERMIT EXPIRES IF WORK IS NOT STARTED
$%( WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESSBUILDING USE
I 15fas• rb Dr . RESIDENTIAL � COMMERCIAL OTHER-
OWNER'S
THER
OWNER''S''��
ROOF
NAME
9_1,5I C Lee. FIREAR DOUS COVERING
rI L rr AREA CLASS
ADDRESS 118 1 TA71 �Vn EXISTING ROOF COVERING
PHONE �J i 7- 7Z. NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
1 ✓
W.h I T�O�1�/Y TO BE REMOVED TO BE RETAINED
NAME
Q `� - TYPE OF ROOF COVERING
ADDRESSCITY&ZIP 149( IOIM Oho— Ayie 1 11 V) `109G qsl l V EXISTING
PHONE �-AS'I oS0 BUILT-UP ROOF
LICENSE �1 ASPHALT SHINGLES
NUMBER �IS9 g3� WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm the,I am licensed under provisions of Chapter 9(commem
eing with Section 7000) of Division 3 of the Business and Professions Code, WOOD SHINGLES
ndmy license is in fu and effete !1 J
Liceme class 1 LA.Number 9 IO
Dau contrenor" OTHER (SPECIFY)
OW NE RBUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Lew for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
or County which requires a permit to construct, alter, improe, demolim,or
rePeb env %fru=tura, prior to its issuance, also requires the applicant for such BUILT-UP ROOF
permit to free a Signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
0f Division 3 of the Business and Professions Code)or that he is exempt mere ASPHALT SHINGLES
d from and the basis for the alleged exemption. Any violation of Section.5 V
.•„ 7031by any.applicant for a permit subjects the applicant to a civil Penalty
of not more that five hundred dollars($500).): WOOD SHAKES
❑ I, a owner of the property,or my employees with wages as their sole
Compensation,will do the work, and the structure is not intended or offered
for sale (Sec. '1044, Business and Professions Coda: The contractors License WOOD SH INGLES
Law does not apply to a r of Property who builds or improves thereon,
and wino rl oes such work Minse Ifor through his own employees,provided that
r
such improvements are not intended p offered for sere. If, however, the OTHER (SPECIFY)
building or improvement sold within une year of completion. the owner
builder will hive the burden of proving that he did not build or improve for
purpose I as PROVIDE I.C.B.O. REPORT NO.
❑ I, . st the Properly, a exclusively contracting with licensed
contrectarz t° construct the Project (Sac. )044, Business and Professions "
oda: The Contactors License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who connects for such projects with a
cpntroctpr(s) licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Se=. ,B.a P.C.fbr this FASTENER
OwnPlner her DateWORKERS'COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self-insure,or a car TYPE SenC.O
Pficate of Workers'Compensation Insurance,or a certified copy thereof(Se=.
voo00V LIeab.0 /��1 Company _ IIfISS�S� %•'� 1 If
ee py is horn. y wrnished. LENGTH 4/�
Applicant iBed copy is Tiled wij{ lie 'ty lryzpgctip�tli;'sion.
-''//��IFI N FROM " FEE SUMMARY
CE RTIFIC E(SF EXEMPTION FROM WORKERS'
MPbe completed
ON INSURANCE "1
(This section need not be completetl it [M19 permit is for one hu ntlretl dol-
lays IS 00)or less.) VALUATION o
I certify that in the performance of the work for which this permit is
issued, 1 shall not employ any person in any manner so as to become subject
to me Workers'Compensation Laws of California. /
Date nt
Applica
NOTICE TO APPLICANT: If, after making this Certificate 0f Exemption, PERMIT FEE T j�
you should become subject to the Workers Compensation provisions of he
Labor Code, you must forthwith comply with such provisions or this permit
shall be deemed revoked. DATE OF APPLICATION
I =ratify that 1 have read this application and state that the above inform.
[ipn is correct. I agree to comply with all City and county ordinances and
state.laws relating to building construction, and hereby ere morixe reprezem (4r
tatives of this city[o enter upon the above'mentioned property for inspection s
purposes. -
(We) agree to say indemnify and keep harmless me City of Cupertino PERMIT VALIDATION;
Chains t liabilities,judg dn[s,costs and expenses which may in any way accrue
ages zt saitl City in con/eduenc °f[h an[ing°f this permit
Signalu re of A licanl/Camrec[br Date
REQUIRED ff' PRE-INSPECTION IN-PROCESS INSPECTION FIN AL INSPECTION 11
INSPECTIONS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
[NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY