R-0147 PERMIT R— 0147
APPLICATION FOR CITY OF CUPERTINQ� NUMBER
R—
PERMIT
INSPECTION DIVISION J/� PERMITE ,DN
' PERMIT EXPIRESESIF WORKORKIS NOT STARTED
>(4 .- •� 180 DA S F DAMS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
4, I LDING ADDRESS /y BUILDING USE
1132 P U so RESIDENTIAL _ COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
GC
NAME k7 /l �a7 Jl�/e FIRE COVERING -
g K / AREA CLASS /T
EXISTING ROOF COVERING
.ADDRESS �,_
PHONE �5��' ` � NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S '
a �0 / TO BE REMOVED TO BE RETAINED I
NAME r7/ /S 0 T, 'y 9 TYPE OF ROOF COVERING '
ADDRESS;
•
CITY&ZIP 2 q D� fob wl/ EXISTING
S4 Al tot—I/ Cwa J 9f /a/ 8- BUILT-UP ROOF
PHONE Z7 y=y/L9l
LICENSEASPHALT SHINGLES
NUMBER 3 3 a — /S WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 nommen' WOOD SHINGLES
ing with Section 70001 f Division 3 of the Business and Professions_Code,
and my license is iy Hull antl effect. J -Jp
D.1 cy�- ! 3�� LIC.Number OTHER (SPECIFY) '
Date contractor �y
OWNER-BUILDER.DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
rrecounty whichrequires a permit 10 construct, alter, improve, demolish,or
pany structure, prior to Its issuance, also requires the applicant for such BU I LT-UP ROOF
Permit to file a signed statement that he is licensed pursuant to the provisions
o+ the Contractor's License Law (Chapter 9 (commencing with Section 70001
r- m Division 3 Of the 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 permit subjectsthe applicant t0 a civil penalty
of hot more that five hundred dollars($500).1: WOOD SHAKES
❑ 1, as owner of the property, or my employees with wages as their sole
compensation, wu1 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
Low it as not apply t0 an Owner of property who builds or improves thereon,
and who does such work himself or through his own employees,provided that
such provemen is a not intended or offered for sale. If, however, the OTHER (SPECIFY)
buildiimng or improvement is sola within one year of completion, the owner.
builder will have the burden of proving that he aid not build or improve
purposoof sale.). PROVIDE I.C.B.O: REPORT NO.
❑ I, as owner of the property, am exclusively contracting with licensed
on tractors to construct the project (Sod, 7044, Business and Professions y,
Cud e: TheContractor's License Law does not apply to on owner of property PROVIDE MFGR:iINSTALLATION SPECS.
Who builds or improves thereon, and who contracts for such projects with a �`
contracm r(s)licensed pursuant to the Contractor's License Low.
❑ 1 am exempt no., Sec. .B.&P.C.for his FASTENER
reason
Owner - Dote
WORKERS'COMPENSATION DECLARATION ,} ( sl�ljp�
I hereby affirm that I have a certificate of consent to self.insure,or a ca,. TYPE "%V
tlflcate of Workers' Compo tion Insur o or a certified copy thereof(Sec.
300q Lab '! ��P� [' ,(
PolicyN ✓oy0 C.rr/pann Sfw ;OL 5�av LENGTH
Curti d copy is of ishod. -
Cel' li h h 'ty' dlt•izian.
Ap"""111 �G{4 w lirl�d�q'�``�� FEE SUMMARY
CERTIFICATE OF EXEMPTION FROM YypAKERS
COMPENSATION INSURANC
(This section need not be completed if the permit is for one hundred dol. n
Isis($100)or less.l VALUATION 22 d
I certify that in the performance of he work for which this permit is
sued, I Sr not employ any person In any manner s0 as t0 become subject
to the Workers'Compensation Laws of Ci lifornia.
Date Applicant Szi t
NOTICE TO APPLICANT: If, after making his Certificate of Exemption, PERMIT FEE 3a fE/JM C C�
you should become subject to the Workers' Compensation provisions of the
Labor Code,you must forthwithcomply with such provisions or this permit DATE OF APPLICATION
shell be deemed revoked.
I certify that I have read this application and state that the above informs
tion is correct. agroo to comply with all city and county ordinances and
state laws relating to building construction, and hereby auhorixe represer,
Carves Of this city to enter upon the above mentioned property for inspection
purposes.
IWa) agree to save, indemnify and keep harmless the city of Cupertino " _ -PERMIT VALIDATION
against liabilities,judgments,costs and expenses which may in any way accrue
agepns dl C i cense f the granting of this Permit.
�Itgl�I a ofpplicam/ContractV Oato /
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS hINSPECTOR DATE INSPECTOR Di INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY