R-0233 PERMIT R- 0233
APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
DIVISION . PERMIT E REROOF PERMIT PERMIT EXPIRES IF WORK IS NOT STARTED
NIT DAYS OF PERMIT ISSUANCE OP
130 DAYS FROM
LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
OI�I y f RESIDENTIAL_ COMMERCIAL OTHER
-ewroeRs c.oNrRAarbR
SE�I 'Ty HAZARDOUS ROOF
NAME. � ����� �yErC/"PFIRE COVERING
AREA CLASS
ADDRESS
��Zs-13 "ABtIRV 6` ZD r 5 rJ EXISTING ROOF COVERING
o n �j '
PHONE d0 — .7 NUMBER OF EXISTING COVERINGS
OWNER TO BE REMOVED TO BE RETAINED
NAME_ 1484 AIR5 WEZVA/Y I TYPE OF ROOF COVERING
ADDRESS, � �� '. EXISTING
CITY&ZIP
PHONE 6-,5 S� BUILT-UP ROOF
LICENSE /7 /2Z ASPHALT SHINGLES -
NUMBER L iWOOD SHAKES
LICENSED CONTRACTORS DECLARATION /
I hereby affirm that I am licensed under provisions of Chapter 9(commem WOOD SHINGLES r
cing with Secdon 7000) of Division 3 of the Business and Prolessiyns�Code,
and my Iicens fo ce and effect. �1r�/f—�
License Cl. Lic.Number
Dat. Contractor OTHER (SPECIFY)
01ANER BUILDER DECLARATION
1 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
Linty which requires a permit t0 construct, sitar, improve, demplish,or
�epe�any structure, 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
of the Contractor's License Law (Chapter 9 (commencing with Section 7000) }
of Division 3 of the Business and Professions Code)or met he Is exempt mere ASPHALT SHINGLES
Plain and the basis for the alleged exemption. Any violation of Section s
7031.5 by any,applicant for a permit subjects the applicant to a civil penalty
` of not more that five hundred dollars($500).1: WOOD SHAKES A
❑ 1,as owner of the property, or my employees with wages as their sole +}
compensation,sale wn1 do the work, and the structure is not intended or offered WOOD SHINGLES 1
for le (Sec. 7044, Business and Professions Code: The Contractor's License
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 improvm
recants a r
not intended p offered for sale. If, however. the OTHER (SPECIFY)
building or improvement is sold within one year of c mpleliOn;the owner
builder will have the burden of proving that he did not build or improve for
purpose of Sale.). PROVIDE LC.B.O. REPORT N0.
C] I, a of me property, a exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds Or improves thereon, and who contracts for such projects with a
contractor(s) licensed pursuant m the Contractors License Law.
❑ 1 am exampl.under Sec. .B.&P.C.for this FASTENER
reason
f Owner Data
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self-insure,or a TYPE
tificate of Workers'Compensation Insure a or a c in led cppv lire of(Sec.
3800,Lab. c Lo L
Policy N ) Cornpeny '
8 Cart yis hereb I niched. LENGTH
Celli Ie y is tiled It the ci
Applicant FEE SUMMARY
ERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE '
(This section need not be completed if me permit is for one hundred doh
Tars($100)Or mss.) .. VALUATION
I certify that in the performance of he work for which this permit is
isse lbm hallLaws
1 e11 Pers n not employ any o in any manner SO as to become subject
to No Workers'Compensation of California.
Data Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, PERMIT FEE
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
shag be deemed revoked. _ DATE OF APPLICATION
I certify that I have read this application and state that the above informs
tion is correct. I agree to comply with all city and county ordinances and
state laws relating to building construction, and hereby authorize mpreven
talivesiOf this city l0 enter upon the abovementioned property for inspection
pulpitses.
(W ) agree to save, Indemnnr d keep harmless ma Cty f Cup§§§nine PERMIT VALIDATION
liabili he lir gm an
pensesw ch me y' way,Ccrue
a n t said Ci ,i� '7.11 a �,n tin� o�his par /
.:-f i Signature of Applicant/Contractor Dara /
V REQUIRED ,PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR A::15 INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY