R-0179y
PERMIT
FOR CITY OF CUPERTINO NUMBER R_ 0179
APPLICATION
INSPECTION DIVISION PERMIT E
REROOF PERMIT PERMIT EXPIRES IF WORKORKIS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
180 DAYSS FROMLAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
ESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
/�
NAME �A"i of ���S//h
FIRE COVER
AREA CLASS ING
-
EXISTING ROOF COVERING
ADDRESS641 L, 997901 C%
a 1
��
NUMBER OF EXISTING COVERINGS
PHONE '� eZ
CONTRACTOR'S
/ /vn�
TO BE REMOVED TO RE RETAINED
Y� *V,,C1� G
NAME / t� .�f'f TYPE
OF ROOF COVERING
EXISTING
!/
ADDRESS, / p �" �, 7j—/3
CITY & ZIP
qQ-�
�/�
BUILT-UP ROOF
PHONE
ASPHALT SHINGLES I
LICENSE 6
NUMBER S S -I—
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
r ins Of Chapter (commen-
hereby affirm that I licensed Pro -
cing with Section J000l of Division 3 of the Business and Professions Code,
WOOD SHINGLES _/
antl my IicnnEa' fuco and effect.
��-.pr`
Licedse class LIc. NumberrZ
OTHER (SPECIFY)
Data 7— 1—& Contractor
OWNER -BUILDER OECLA TI N
I hereby affirm that I am exempt from m¢ ontractor's License Law for
PROPOSED
the following reason. (Sec. 7031.5, Business a d Professions Code: Any city
unty which requires a permit to construct, alter, improve, tlenrolish,Or
�apan any structure, prior to its issuance, also requires me applicant for such
BUILT -Up ROOF -
ennt that he is licensed pursuant to the provisions
Permit to file a signed ztatm
of the Contractor's License Law (Chapter 9 (commencing with Section 70001
of Division 3 of the Business and Professions Cade) or that he is exempt there-
ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Sac[ion
7031.5 by any, applicant for a permitubjects the applicant to a civil penalty
of not more in at five hundred donars ($500).1:
WOOD SHAKES
❑ I, as owner of the property, or my employees with wages as their sole
mpensation, will do me work, and the structure is not intended or offered
for sale (Sec. Jo44, Business and Professions Coda: The Connector's License
WOOD SHINGLES
Law does not apply to a r of property who builds or improves thereon,
end who does such work himselfOr through his own employees, provided that
such improvements are not intended or offered for sale. If, however, the
OTHER (SPECIFY)
building Or improvement is sold within o e year of completion, Ina O
bulltler will have the burden of proving that he did not build or improve for
purpose orsme.L
PROVIDE I,C.B.O. REPORT NO. '
❑ I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project ($tic. 7044, Business and Professions
'
code: ThaContractor's LicenseLawdoesnot apply toanow of property
PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who contracts for such projects with a
contractors) licensed pursuant to the Contractor's License Law.
❑ I am exempt untl¢r S.C. ,B.&P.C. for This
Y�anr�ar�z�
f lZy(1]Jw.ly-j Cil
oOwner Data—
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self insure, or a car
q
TYPE Ii % �nnr
,ific ate of Workers C mediation Insurance,tied copy thereof (Seo-
rII
—A
$0
3800
0, Lab. C,1. /f ��j
P I'[ N / CO
certified onv is nereb wmish¢d'
LENGTHNty of
erti -e000V is filetl i[M1 me inippciiOn tliviziOn.
—_1
FEE SUMMARY
Ap_ "
RTIFICATE OF EXEM TION FROM WORKERS'
4j
COMPENSATION INSURANCE
IT section need not be completed if the permit is for one hundred dol-
Iars ( 00) or iess.l
/' )
I certify mac in the performance of the work for which this parmit
VALUATION'
issued, I shall not employ any person any manner so az to become subject
to the Workers' Compensation Laws of Californian
Date Applicant
NOTICE TO APPLICANT: atter making this of Eof the
PERMIT FEE
Workers Compensation Provisions me
you zM1Cod become su o Compensation
fort i h c nsisa
you must forthwith comply with such provisions 0)r this permit
DATE OF APPLICATION
hell diem
shell be seamed revoked.
above nces an
certify that I neve reed this application and state that county
stat is correct. agree to comply with all city and county arsine rotes and�—
' j I
sat
z,a,e relating to building cons and hereby aerty fora p
J
s diem
this city to enter u ton [M1e above mentioned property for inspection
s 01 n the above
PERMIT VALIDATION
OseS.
pures s.
purposes.
(we) ree to save, i difV keep harmless me c1W of Cuper,ino
agam abilities, ju encs, c �xpenzez which may III way accrue
I aid City consequ f the granting of this permit.
/ i S
��—
r
igna[ur pl Appli rot Onlre[[Or Data
PRE -INSPECTION
IN -PROCESS INSPECTION
- FINAL INSPECTION
EQUI RED
INSPECTIONS
INSPECTOR DATE
INSPECTOR DATE
INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY