R-0159 t
PERMIT R_ 0159
APPO
APPLICATION FOR CITY F UUPERTINO'" A NUMBER
REROOF PERMIT INSPECTION DIVISION - PERMIT EXPIRATION
,y/ PERMITEX PIPES IF WORK IS NOT STARTED
191 THIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
1
1
al D -7-1lo ta Z.4yoRESIDENTIAL COMMERCIAL OTHER—
OWNER'S /
NAME Z HAZARDOUS
THEROWNER'S
HAZARDOUS ROOF
NAME >r— �/ FIRE COVERING
/ AREA CLASS
ADDRESS 77IU(�/VO EXISTING ROOF COVERING
il
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'
.r ��� /Y�p�' C.jD/l7r.'(T TO BE REMOVED TO BE RETAINED
NAME
�J �} ' / /J J 1 c TYPE OF ROOF COVERING
ADDRESS, �5,2 7 �J /4. wig/ ao /K'� /,SO rX r
CITY& ZIP r/ XISTING
PHONE 3 J BUILT-UP ROOF
LICENSE `� 7 7Z ASPHALT SHINGLES
NUMBER 73 ..7
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby off I'M
'be,I am licensed under provisions of Chapter 9(common
eine will, sectio 7000) of Division 3 of the Business aW Professions code, WOOD SHINGLES -
andmy licersa�n fall clpp HecL
License Class`' —p� Lic.Number
Datey— :: �o-� contractor 3r3 727 2— OTHER (SPECIFY)
OWNER-BUILDER DECLARATION is
I hereby affirm that Ilam exempt from the Contractors License Law for PROPOSED
the following res (Sec. 7031.5, Business and Professions Coda: Any city
rrecounty whichrequires a permit t0 construct, alter, improve, demolish,or
pany structure, prior to its issuance, also requires the applican'for such BUILT-UP ROOF '
permit [ fit signed statement that he s licensed pursuant t0 the Provisions
of'n C ' tar's License Law (Chapter 9 (Commencing with Section 7000)
of Division 3 of the Business and Professions code)or that he s exempt there
s - ASPHALT SHINGLES
y. from and the baps for the allegedlane exemption. Any vol at an of Section
of n 5 e y pave hundred
fora permit 500).)z the applicant to e civil penalty
.t,-y: m no'mora that Rvenunarad dmlars($soo1.1. WOOD SHAKES
❑ I, as owner of the property, or my employees with wages as their sola
compensation, will do the work, and the structure is not intended or offered WOOD SHINGLES
for sale (Sec. 7044, Business and Professions Coda: The Contractor's License
Law does not apply to an owner
of property who builds or improves thereon,
and who does such work himselfor through his own employees,provided that
such improvements are not intended or uttered for sale. II, however, he OTHER (SPECIFY)
building or Improvement Is sold within one year Of completion, the owner
builder will have the burden Of proving that he did not build Or Improve for
purposeolsam.), PROVIDE I.C.B.O. REPOR:TNO.
❑ I, as Owner of the property, anxclusively contracting with licensed 1
contractors to construct the project (So.. 7044, Business and Professions '
ode: The Contractors License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who The
or improves thereon, and who contracts for such projects with a
contractor(s) licensed pursuant to the Contractor's License Law,
❑ 1 am exempt under sec. ,B.a P.e. f/mis� FASTENER
sner Dam
W ORKERS'COMPENSATION DECLARATION1 C//� q
I hereby affirm that nava a affil lcaie ur consent self.I esu ra O 1 TYPE ✓ • �"/�
tificate of Workers' Compensation Insurance,or a cartified copy the of(Sac, f f
3800, Lab.C•1. 1`
Policy No. Company
L3 Certified copy is hereby furnished. -.r'• LENGTH
Certified copy is riled with the city impor
con division
Applicant FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol.
I...($100)or Ass.) VALUATION �G
I certify that in the performance Of Ih rYyhp hicn miz permit is
ped, I shall of employ any person i o o bocome subject
to the W kers'Com notion Lewz ria.
Date ApPlicanl
NOTI TO APPLICANT: If, after py. Ing this Cera tato of e.a�mporon. �- PERMIT FEE
you should become subject to the Wdrkers' Compensation provisions of the
Labor Coda, you must forthwith comply with such provisions or this permit
shall be deemed revoked. / G DATE OF APPLICATION
I certify that I have read this application and state that the above informs
tion is correct. I agree to comply with all city and county ordinances and
state laws relating to building construction, and hereby authorize reprmem
'olives of this city 10 enter upon the above mentioned property for inspection
purposes.
(w ) agree U.-iie s, indamnify and keep harmless the City of Cupertino PERMIT VALIDATION
x_ agains, rl se , cd^ e A costs and expenses which may in any way accrue
ego. t eo uenee of the granting of this permit. /—er
TO"i
y�z3 —rs1
�h ign Ii'uof A VContractor 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