R-0203 PERMIT
APPLICATION FORCITY OF CUPERTINO NUMBER R- 0203
REROOF PERMIT u NSPECTION'DIV SION PERMIT E
f PERMIT EXPIRES IF WORKORKIS NOT STARRED
C i / 2Z 1ST SBODAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
�• BUILDING ADDRESS J BUILDING USE
20t5(oY, 7,T1 ��' , Z {D.�o00
RESIDENTIAL COMMERCIA OTHER
OWNER'S
y -�Y�Q—PPEP TIES HAZARDOUS ROOF
NAME FIRE COVERING
(p� p0 Tl2E2.o n-Loichi PC. AREA CLASS
ADDRESS ,Z I- f F209` 4,Ig X-r. 44 V 41 D3 - EXISTING ROOF COVERING
PHONE _ , NUMBER OF EXISTING COVERINGS 0�`e-
CONTRA OR'S +
' TO BE REMOVED_0_1TO BE BETAINE yoga- y,,_
NAME ✓�Ggt�1{ i NeTAxaCn2A,Is GnTYPE OF ROOF COVERING
,ADDRESS,
- CITY&ZIP IlSco77 d " S.WN779 GLA«GA 11,9 034_ EXISTING
PHONE — GQ BUILT=UP ROOF U_
ICE SE ASPHALT SHINGLES
NUMBER
.WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(Cole
ing Witn Section 7000) of Division 3 of the Business and Professions coda, WOOD SHINGLES
end my license's' Lull force and atleco p
License Class , LiC.Number! bb til 6
C.ntraptor OTHER (SPECIFY)
OWNE RBUILDER DECLARATI OP
I narety
affirm that I a exempt from the Contractor's License Law PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
or county which requires a permit t0 Construct, alter, improve, dem"lish,or
repair any structure, prior to its issuance, also requires the applicant for such BUILT-UP ROOF �/ +
paimit t0 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 OMSion 3 of me Business and Professions Code)or that he is exempt there ASPHALT SHINGLES -
from and the basis for the alleged exemption. Any violation Of Section
7031.5 by any applicant for a permitubjects the applicant 10 a civil penalty
of not more that five hundred dollars($500 ).): WOOD SHAKES
❑ I, as o ar of the property, ormV,emplovaes with wages as their Sulu
Color
peosis will do the work. and the structure is not intended or Offered WOOD SHINGLES
for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not apply t0 an owner of property win"builtlz or improves theraCn,
and who does such work himself or through his own employees,provided that
such improvements are not intended or
offered for sale. Ii, h..,ni r, the OTHER (SPECIFY)
building o mpr.vemanl is sold within one year of c mpletion, the Owner
builder will have the burden of proving that he did not build Or Improve for '
pgmoseofsale.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am exclusively contracting with licensed
ontractorsto construct the project (Sec. 7044, Business and Professions
Code: TheContractor's License Law does not apply to an Owner of property PROVIDE MFGR. INSTALLATION SPECS.
who-builds r Improves thereon, and who contracts for such projects with a r �..(
Contracto r(s) licensed pursuant to the Contractur's License Law. aWO-ra Cd't's'1 • -� N n(
❑ am exempt under sec. ,B.&P.C.for his FAS ER
rea
on
Owner oat.
WORKERS'COMPENSATION DECLARATION d
l hmeby affirm hat I have a Certificate of consent to self.insure,ora car. TYPE
nficato of Workers' Compensation Insurance,or ancertified copy thereof(Sea
38110 Lob.C') / ♦ /'
1 No.� Company�t�G-[l of Faw�
ti+ied copy is hereby,to nisM1¢tl pp
anuiad Cour is+ued wih me aloCtifrT'DI'Y .p�' �6,11 7P
LENGTH f +
A loan FEE SUMMARY
CERTIFICATE OF EXEMPT IO FR O E s 7
COMPENSATION INSURANCE - - V 1
(This section need not be completed if the permit is for one hundred dol- ,ff /y��� /
lots(Stour or last.I VALUATION"'/ 7
I Certify llh t in the performance of the work for which this permit is
isaue4 Sn Ag
e not employ any person in any manner so as t0 become subject /•O t 3 Q
m tno Workers'Compensation Lewis of California. �G /
DatApplicant Y �/`'� 2G3
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
shall be deemed revoked. DATE OF APPLICATION
FF r
I Certify that I have read this application and state that the above intorma C s
tion is correct. I agree to comply with all city and county ordinances and I
state laws relating to building construction, and hereby authorize represen. T`f/ / 6
[coves of this city to enter upon the above-mentioned property for inspection ✓ G
Purpose . -
(wa) agree to s indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
- ,against liabilities, judgments ,costs and expenses which may in any way accrue
I against laid City in Consequence of the granting of this permit. ,
a 3 t�4'IcN WQ STs•✓- TIO.v ��y /v/ �C r' t
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