R-0207Ac,
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PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R-0207
INSPECTION DIVISION PERMIT E
REROOF PERMIT PERMIT EXPIRES IF WORKORKIS NOT STARTED
WITHINDAMS OF PERMIT ISSUANCE OR
180 DAYSS FROM LANs CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
P
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
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HAZARDOUS ROOF
NAME6100d CC Ir{7 e54 Ili
FIRE COVERING
AREA CLASS
' EXISTING ROOF COVERING
ADDRESS
S
NUMBER OF EXISTING COVERINGS 1
PHONE -
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CONTRACTOR'S
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TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
NAME l� h fn o Iw C_o • .LY1G .
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CDDR&ZSP/U 8O — M ��/KGLa�G /h.P III LIeLJ
EXISTING
BUILT-UP ROOF
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PHONE - %��_�b /
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ASPHALT SHINGLES
LICENSE //
NUMBER p2 b
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
/ 1 hereby affirm that 1 am licensed under provisions o1 Chapter 9 (commem
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lung with Section 7000) of Division 3 of the Business and Professions Code,
WOOD SHINGLES
and my license is in lull force and effect
-License Class Lic. Number
OTHER (SPECIFY)
Date Contractor
OWNER BUILDER DECLARATION
Hereby affirm that I am exempt from the Convector's License Lew for
PROPOSED
the followingleason. (Sac. 7031.5, Business and Professions Code: Any city
Or county which requires a permit to construct, alter, improve, eemoliSh,Or
- repair any structure, prior to Its issuance, also requires the applicant tarsuch
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 Section7000)
OI Division 3 of the Business and Professions coeur or that he is exempt them
ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any, applicant far a permit subjects the applicant t0 a civil penalty
of not more mat rive hundred dollars (500).1:
WOOD SHAKES
❑ 1, as owner Of the property, Or my employees with wages as their sole
comn will do the work, and the structure is not intended or offeree
spensatioal
far e (Sec. 7044, Business and Professions Code: The Contractor's License
WOOD SHINGLES
Law does not apply to a owner Of property who builds or improves thereon,
and who does such work himself or through his own employees, provided that
m not intended o offered for sale. If, however, the
pch improveents a r
OTHER (SPECIFY) '
ng Or improvement is sold within one year of completion, the owner.
buil Fit
builder will have the,burden of proving that he did not build Or improve for
Purpose of sale.).
PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the property, am exclusively contracting with licensed
ontrac tors to c nstmct me 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
combec[Or(s) licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Seo. ,Bra!`C. for this
reason
FASTENER
Owner Date
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to sell insure, o
TYPE
tificate of Workers' Compensation Insuran5� ora/a�-pcertif copy thejeorf (Sec.
LQ
3800, Lou. C.). :5110'� G�
7
W I
Policy No. Cwnpenv� / C lip"
by fur "shed.
F
p Cer[ifietl <opV
LENGTH
❑ Ce[llletl cop lad.�yf ma pity insp«[fan division.
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FEE SUMMARY
Applicant
4- 9—si
CERTI 61CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for One hundred not
lets ($100) or less.)
VALUATION 00 O
certify that in the performance of the work for which this permit i
issushell not employ any person In any mer so as 10 become subject
to the Workers' Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: I1, this Certificate o1 Exemption,
/T,C7`Oma—
after making
youshould become subject to the Workers' Compensation provisions of the
PERMIT FEE
Labor Code, you must forthwith comply with such provisions or this permit
DATE OF APPLICATION
.hall be deemed revoked.
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I certify that I have read this application and state that the above informa.
tion is correct. I agree to comply with all city'. and county ordinances and
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state laws relating to building construction, and hereby authorize represem
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hPives of this city to enter upon the above mentioned property for inspection
PERMIT VALIDATION
purposes.
(W )to e, ndemnifno keep harmless the City o1 Cupertino
jCs and expense which mar]yy in any way accrue
against li it s ud touts os
a8eitY granting O1this per
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SI atu ra of Applicant actor Deta
PRE -INSPECTION
IN -PROCESS INSPECTION
FINAL INSPECTION
REQUIRED
INSPECTIONS
hINSPECTOR DATE_
INSPECTOR DATE_
INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY