R-0181 PERMIT R_ O 18�
APPLICATION FOR CITY OF CUPERTINO NUMBER v
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
y WITHIN IOD DAYS OF PERMIT ISSUANCE OR
180 DAYS AVS FROM LAST CALLED INSPECTION.
BUILDINGADDRESS BUILDING USE
Cj (� �YI de. RESIDENTIAL k COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME KU ll Loi, ri tar — FIRE COVERING
(' AREA CLASS
ADDRESS
101 l S+a-�-�oY� -D1' EXISTING ROOF COVERING
PHONE251 -4 13z NUMBER OF EXISTING COVERINGS
CONTRACTORS /1 {�
NAME IA J11( 0,k er l O TO BE REMOVED TO BE RETAINED
pp ��`` TYPE OF ROOF COVERING
ADDRESS CITY&ZIP l4'DI PDyy10YNQ Ade, Say) SOSe �SfI O EXISTING .
PHONE (05;-b BUILT-UP BUILT-UP ROOF r
LICENSE ASPHALT
ASPHALT SHINGLES
-
NUMBER o
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION _
I hereby affirm that I am licensed under provisions Of Chapter 9(commen.
Bing with Section 7000) of Division 3 of the Business and Professions Code, WOOD SHINGLES
and inlicens full for lid If vct.
e
Licnse Class�f Q Lic.Number µS9838
Data ri Contractor If�t,• OTHER (SPECIFY)
f
OWNERBUILDERDECLARATION
hereby affirm that am exempt from the Contractors License Lew for PROPOSED -
the following reason. (Sec. 703 .5, Business and Professions Code: Any city
or County which requires a permit to Construct,alter, improve,dem Oliah,0r
repair any svactara,prior to its issuance,also requires the applicant for such BUILT-UP ROOF
Permit
to file a signed statement that he is licensed pursuant to the provisions
-h of the Contractor's License Law(Chapter 9 (commencing with Section 7000)
t of Division 3 of the Business and Professions Con.)or that he is exempt there' ASPHALT SHINGLES
�,- r from and the basis for the alleged exempt ion. Any violation sof Section ,
7031.5 by any applicant fora permit subjects the applicant to a civil penalty
L of not more that five hundred tlollars(9500).1: WOOD SHAKES
i. ❑ I'as Owner of the property, q hill,employees with wages as ir sO10
compensation,mpation,will do the work, and the structure is not intended or offered WOOD SHINGLES
for sate (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply t0 an Owner of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that
buch improvements are not intended or Offered for sale. If, however, me OTHER (SPECIFY)
uilding o improvement Is sold within one year of completin, the oowner.
builder will have the burtlen of proving that he did not build or improvefor ^4
purpose of sale.). - PROVIDE LC.B.O. REPORT NO.
❑ I, as owner of the property, am exclusively contracting with licensed
contractor. t0 construct the project (Sec. 7044, Business and Professions
code: The Contractor's License Law does not apply to an owner of properly PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who contracts for such projects with a
contractor(s)licensed pursuant 10 the Contractor's License Law.
❑ 1 am.exempt under Sec. ,R.a P.c.to, his ason FASTENER
Ow Date
Owner WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self insure,or acer. TYPE Sent o
tifieate of Workers' Compensation Insurance,or e certified copy thereof(Sec.
3000,L hili
Poli. I � mpany
eertdied copy is here y l mish0gL 1551 Oh LENGTH Q 1/Z .
canifi d copy is file wi!t c 'tv inip non division.
Applicant Q, FEE SUMMARY
CERTIFICA E OF EXEMPTION FROM WORKERS'
C PENSATI O NINSURANCE
(This recline ...d not be completed if the permit is for one hundred dab
lars(S100i or less. VALUATION
certify that in the performance of the work for which this permit
issued. I shall not employ any person in any manner so as to become subject
to the Workers'Compensation Laws of California, -
DeteApplicant y�.{
NOTICE TO APPLICANT. If, after making this certificate of Exemption, PERMIT FEE / / SX
you should become subject to the Workers' Compensation provisions of the
Labor code, you must forthwith comply with such provisions or this permit DATE OF APPLICATION
shall be deemed revoked
I certify that 1 have read this application and state that the above informs
tion is correct. 1 agree to comply with all city and county ordinances and.
state laws relating to building construction, and herebyauthorize rapresen.
tatives of this city to enter upon the above mentioned property for inspection /
purposes
(we) agree to s indemnify and keep harmless me City of Cupertino PERMIT VALIDATION
against liabilities,judgments,costs and expenses which may in any way accrue
t"+•-- age nit ram Cl tv in Itsequence Oi he granting of this permit. �`//`
•: Signature of Pli ent/Contractor Date 7// / C1 f
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY