R-0270PERMIT R_ 02
APPLICATION FOR CITY OF CUPERTINO NUMBER 70
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
- WITHIN I80 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
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•
RESIDENTIAL COMMERCIAL OTHER
OWNERS'
-
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NAME //I�/r/� MLTZ
ROOF
HAZARDOUS COVERING
FIRE
AREA CLASS
ADDRESS c2 ox Sc /SU ��!/ s
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
TO BE REMOVED � TO BE RETAINED /
CONTRACTOR'S /C/1 `
NAME p bilk P 00 l �/
/���I� b
TYPE OF ROOF COVERING
L `('�7 �/•� /�v
ADDRESS, 2L�/`3 FOWji lc- Atli. ✓11/I VI `/Ak
CITY &ZIP l
EXISTING
BUILT-UP ROOF
PHONE Y0 n —
LICENSEJ� 1 ��
NUMBER
ASPHALT SHINGLES
WOOD SHAKES
'LICENSED CONTRACTORS DECLARATION
'
I hereby affirm that I am licensed under provision, Ot Chapter 9 (comment
ing Wim Se=tion 7000) of Division 3 of the Business and Professions Cade,
WOOD SHINGLES kl
and my license is in full force and effect.
License Class Lic. Numr
Data beContractor
OTHER (SPECIFY) -
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for
the fallowing reason, (Sec. 7031.5, Business. and Professions Code: Any city
or county which requires a permit to construct, alter, Improve, demoloh,or
PROPOSED
.
repay env structure, Prior to its issuance, also requires the applicant for such
permit to file a signed statement that he is licensed Pursuant to the provisions
Df the Contractor's License Lew (Chapter 9 (commencing with Section 7000)
BUILT-UP ROOF
of Division 3 of the Business and Professions Cede) or that he is exempt mere
from and the basis for the alleged exemption, Any violation of Section
7031.5 by any, applicant for a permit subjects the applicant t0 a Civil penalty_.
ASPHALT SHINGLES
of not more that five hundred dollars f%oo)d. v
❑ I, es Owner of the property, Or my employees with wages as their sole
compensation, will de me work, and the structure is not intended or offeree
for sale (Sec, 7044, Business and Professions Code: The Contractor's License
Low (S
does not apply to an owner of property who holds or improves thereon,
WOOD SHAKES p 7
d p
/�
WOOD SHINGLES CQ
City19
Of ^
andwho does such work himself or through his own employees, provided that
4
uP%ft
m improvements are not intended or offered for sale. If, however, the
building or improvement is sold within one year Of completion, the owner
OTHER (SPECIFY)
builder will have the burden of proving that he did not build or improve for
a.
Purpose ofsala.l.
❑ 1„as owner or the property, am exclusively contracting with licensed
PROVIDE I.C.B.O. REPORT NO.
contractors to construct the project (Sec. 7044, Business and Professions
ode: The Contractor's License Law does not apply to an owner of property
- who builds or improves thereon, and who contracts for such projects with a
PROVIDE MFGR. INSTALLATION SPECS.
com actorls) licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sac. - ,B.&P.c. for this on
FASTENER
owDate
WORKERS' COMPENSATION DECLARATION
Ihave o a ter.
hereby affirm that I ensa i n h,ificam of -consent a cent ie copy
of ream of Workers' Compensation Insurance, or a certified copy thereof (Sec.
TYPE
/ /
LENGTH a S-;r?qP&—i
3800, Lab. C.1.
Policy No. Company
Certified Dopy is hereby to the
Certified copy is tilos with me City Inspection division.
FEE SUMMARY
Applicant
CERTIFICATE EXEMPTION FROM WORKERS'
E
COMPENSATION (NSU RANGE
(This($0 section need not be completetl it me permit is for one hundred doh
completed
T'�ry /S
las (sero) or lass.) �
certify that in mo performance of the work for which Perri
VALUATION �[L/C��Z' 7
issued, I shall t employ any person ' V manner z to become subject
co
rz^A�/1✓L
to m�i�l9° tion Laws'y�y9f GGaaLL+qq �p �I
Date Applicant lGR/7 it lLn
- ./� (/✓�
Norl E TO APPLICANT: If, aster Mang (his Carie=am O+ Exemption,
You should become subject to the Workers' Compensation provisions of the
PERMIT FEE
Haan oCode,
a emea.e akea osnwitn comply with such pravemn:Or mis permit
DATE OF APPLICATION
• I certify that I have read this application and state that the above informs
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tion is correct agree to comply with all airy and county Ordinances and
/
state laws relating to building construction, and hereby authorize represent
tetives of Island city to enter upon the above mentioned property for inspection
7 U t \J
PERMIT VALIDATION
�// 9 �e /
purposes.
(we) Arearo soya, indemnifyand keep Harmless ma City of Cupertino
ogoinsmbil itiez, judgments, costs antl expenses wnicM1 may an wayaccrue-
agai t e Ci Vin oqu an IM1e granting of to is perm' ue
jo c0 - �l / i /�5
Si tore of Applica t/ mractor Data
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