R-0266APPLICATION FOR
REROOF PERMIT
BUILDING ADDRESS
OWNER'S
NAME Mr- �-Mys �QhYOS-e-
ADDRESS --ISSN
Terrocq- Cir..
CITY OF CU PE RTI NO
INSPECTION DIVISION
RESIDENTIAL
PHONE 2 5 1 16 -7
3
CONTRACTOR'S
NAME
�!
NAME C� Cr�cS r,-, S� .IC Jt'Ihg �. O1
ADDRESS, Gi.Gg Sglln GS CC,�/'�
CITY & ZIP
G�3 3-73-?SS6 �.
PHONE
LICENSE/I "I O'1Q q
4
NUMBER 1
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under Provisions of Chapter 9 (commem
cine with Section 7000) of Division 3 of the Business d PPlrofessions Code,
and my license it, lbgorce and effoct. q-70 / 49
License Cie. JJ Lm. rvum Car
Data T _ /3_nS Contractor
JJ OWNER -BUILDER OECLARATI0
I hereby affirm that I am exempt from the Contractor's License Law for
the following reason. fSec. 7031.5, Business and Professions Code: Any city
Or c unty whichrequiresa permit t0 construct, alter, improve, demonsh,or
,Open any structure, prior m its is q also requires the applicant for such
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 that he is exempt there
'from and the basis for the alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more that five hundred dollars ($500).): -
❑ I,as owner Of the property, or my employees with wages as their sale
compensation, will do the work, and the structure is not intended or offered
for sale (Sec. 7044, Business and Professions Code: The Contractor's License
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
uch ire prov ements are not intended or offered for sale. If, however, the
t
building o mprovement is sold within one year of Completion, the owner
builder will have the burden of proving that he did not build Or improve for
purpose of sale.).
Cl I, as owner of the property, am exclusively contracting with licensed
contractorsto construct the project (Sec. 7044, Business and Professions
Code: Tho Contractor's License Caw does not apply to an owner of property
who builds or improves thereon, and who contracts for such projects with a
pntractorls) licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec ,B.&P.C, for this
reason
Owner__Date
WORKERS'COMPENSATION DECLARATION
.I M1ereby affirm that I have a certificate of consent to PIT insure,
a car
tifieate of Workers' Compensation Insurance,e
or a certified copy thereof (Sec.
3800• Lab. C.1. raGtA Ir+. n d
Policy -Ito Company S I
❑ Cert'il I y/s'M1.e.reby furnished.
o Carne pWif filet with the city inspection division.
Applicant W r✓6//yrl
C FICA E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE•
(This section need not be completed If the permit is for one hundred dol-
lar: ($100) or lees.)
I certify that in the performance Of the work for which this permit is
issued, I shall not employ any person in any manner so as to become subject
to the Workers' Compensation Laws of California.
Dote Applicant
-
NOTICE TO APPLICANT: If, attar making this Certificate of Exemption,
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,
certify that 1 have road this application and state that the above informa
tion is Correct. igroe to comply with all city and county ordinances and
state laws relating to building construction, and hereby authorize represen-
tatives of this city t0 enter upon the above-mentioned property for inspection
purposes.
(We) agree to s indemnify and keep harmless the City of Cupertino
against Il it sties, /}figments, Costs and expenses which ay' any way accrue
again ;j Cil . Consequence of the grantingo9f lin permy{.� '
Sir a of,IAnfliircent/Contractor Data
NUMB R R- 0266
PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING USE
COMMERCIAL— OTHER__
HAZARDOUS ROOF
FIRE COVERING
AREA CLASS
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS 0 N F
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
EXISTING
BUILT-UP ROOF -
ASPHALT SHINGLES '
,/WOOD SHAKES Med;Pin,s
WOOD SHINGLES
OTHER (SPECIFY)
PROPOSED
BUILT-UP ROOF
ASPHALT SHINGLES
✓WOOD SHAKES M PC�rct'T^ b
WOOD SHINGLES
OTHER (SPECIFY)
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
TYPE 5'rll 111
3
LENGTH 1 /41
FEE SUMMARY I,
VALUATION'
PERMIT FEE -6-03 Se/SX`-1,C • d-2)
q/i /le,(
PERMIT VALIDATION
REQUIRED PRE -INSPECTION IN PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR h INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY