R-0206 PERMIT R_ 0206
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
L`•.. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
IRO DAYS FROM LAST CALLED INSPECTION.
BUILD
ING ADDRESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME �/TQAle 011 yyJ/r O// FIRE COVER
AREA CLASS ING _
ADDRESS G30 S/fPptid/l4 EXISTING ROOF COVERING
PHONE (y / NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
G� /S ,/{ D O,J/.'yg' TO BE REMOVE OF�COVERINBE G NAME TYPE
ADDRESS,
CITY&ZIP g'9S �27s9i EXISTING
PHONE 2 5, _ 7 �� (� I BUILT-UP ROOF
LICENSEASPHALT SHINGLES
NUMBER _73lli
WOOD SHAKES
LICENSED CONTRACTORS under DECLARATION
hereby affirm ma[I of licensed under provisions of Chapters(comma.
ding with section 7000) of Droamn 3 of ma Business and Professions code, WOOD SHINGLES
dna my ficensa iz in II fore a affect. Q -
License Cass Lic Number e 3
Defoe cDECLrPr���/ OTHER (SPECIFY)
OW ER�BUILDER DEC LA RATI
lereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the following res (Sec. 7031.5, Business and Professions Code: Any city
Or county whichrequires a permit to construct, alter, improve,dem Olish,Or
mpev 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 wim Rection 7000)
tK^-•} Of Di Orion 3 of the Business and Professions Code)or that he is exempt mere ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
.•IT 7031.5 by any.applicant for a permit subjects the applicant t0 a civil penalty
Of not more mat five hundred dollars($500).): WOOD SHAKES
^' E] 1, a owner Of the property, O my employees with wages as their sole
Pocompensation,will do the work, and the structure is not intended o offered
or sale (Sec. 7044, Business and Professions Code: The Contractors License WOOD SHINGLES
Lew does not apply to an Owner of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that _
such improvements are not intended or offered for sale. If, however, he OTHER (SPECIFY) -
building or improvement is sold within one year of completion, the on
builder will have the burden of proving then he did not build or improve for
purpose Of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, as o of the Property;am exclusively contracting'with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: The Contractors License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds o improves thereon, and who contracts for such Projects with a
ontractor(s)licensed pursuant to the Contractor's License Law. /
C3I am exempt ender sec. ,B.&P.C.for his
reason
FASTENER _ f
Data
her WORKERS'COMPENSATION DECLARATION 0
I hereby affirm that I have a certificate of consent to calfmldre, a TYPE ?/S( Ali /S
lificate of W o rkers' Compensation Insurance,or a certifiedcopy there 0f ec.
380q Lab.C.1.Policy S/•O *� fYNP
3800, ab Company
car � -o nor b wmirhe�. LENGTH .7
d rn��m 1.v�ir,�L do cion.
A°pfi<a"` ,iaS�g A '�� FEE SUMMARY
CERTI KATE E SATI N N FR M E RS'
COMPENSATION RATION INSURANCE
(This section need not be completed if the permit is for one hundred dol.
ars I$t 00)or less.) VALUATION
1 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 the Workers'Compensation Laws of Californ a.
DateApp ll<ant / ( L_ z-,y
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, PERMIT FEE �l0 JL �Yz I/C 11
you should become subject to the Workers' Compensation provisions of the -
shall be learned Labor Code. uforthwith comply with such provisions or is permit
lbolind. this ♦DATE OF APPLICATION
1 certify that 1 have real this application and state that the above in forma
[ion is correct. I agree to comply with all city and county ordinances and 7//
state laws relating to building construction, and hereby authorize represem
relives Of this city t0 enter upon the above mentioned property for inspection
purposes.
(We) agree to save, indemnify and keep harmless the city of Cupertino PERMIT VALIDATION
aaggaiiinnnsst liabilities,judgments,coinsend expenses whim y any way accrue
/ s�/tl f[Y In cansegypnce [ g of this P$�'l
Affiree of Applican Copltractor Dris/�— 6 s �
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS gNSPECTOR DATE—h INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY