R-0170 PERMIT R_ O17�
APPLICATION FOR' ,,., CITY OF CUPERTINO NUMBER
R—
PERMIT - INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
11 �� BUILDING ADDRESS BUILDING USE
RESIDENTIAL >< COMMERCIAL OTHER
OWNER'S //, i}p
NAME l— -f/��/� CYJ( 1-/A—YY)o J-6 FIREAR HAZARDOUS COVERING - 'r-
- AREA CLASS
ADDRESS / 9b /�s�7 /�-�7 GJ✓ EXISTING ROOF COVERING/
PHONE 3 -Q NUMBEROF EXISTING COVERINGS
CONTRACTO
F}33\BB���L^^^/ TO BE REMOVED TO BE RETAINED
NAME— ���-P ��� � TYPE OF ROOF COVERING
ADDRESS, y� �
CITY SI ZIP / �' / YY/�-<— y EXISTING
PHONE S� —�vY� Zi BUILT-UP ROOF
NUMBER SLQ�lp ASPHALT SHINGLES
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 M1ereby affirm that I am licensed under provisions of Chapter 9 (Common
`/
Chug with Section 7000) of Division 3 of the BPsmass a Prafeasion5 code, WOOD SHINGLES R .
antl my li¢enSa Is I fYll f e snit etf0¢t.
License c1a55 LIc.Number OTHER (SPECIFY) '
Dote 71–� � r Contrecto
6` OWNER BUILDER DECLA ATION -
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
the following reason. (Sec. 703t5, Business and Professions Cotle: Any city
Linty which requires a permit to c mmprove, demolitruct, el ter, imp
repair any structure, prior to its issuance,also reouire5 the applicant for Such BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
.:. of the Contractor's License Law (Chapter 9 (Commencing mncing with Section 7000)
" of Division 3 of the Business and Professions Code)or that he is exempt mere. ASPHALT SHINGLES
from and the basis for the alleged examption. Any violation of Section
7031.5 by any,applicant for a permit subjects the applicant to a Civil penalty
.+
of not mora that five hundred dollars($500).): WOOD SHAKES V
❑ 1,as Owner of the property, Or my employees with wages as their Sole
Compensation, will do the work, and the structure is not intended o offered
for Sale(sac. 7044, Business and Professions Code: The contractors License WOOD SHINGLES
Low does not apply to an owner of property who builds or improves thereon,
and who does such work himself or 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 one year of Completion, the owner
builder will have the burden of proving that he did not build or improve for
Purpose Of sole.). PROVIDE I.C.B.O. REPORT NO.
❑ I. a5 or at the property. a exclusively contracting with licensed
cpntraclors to construct the project (Sec. 7044, Business and Professions
oda: TheContracmrsLicense Law does not apply toa wner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereon, and who contracts for such projects with a
ontractor(s)licensed Pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. ,B.&P.C,for this
Reemn FASTENER
Owner Date
' WORKERS'COMPENSATION DECLARATION
hereby affirm that I have p c lits ticate of consent to self insure,or a
tifietp of Workers' comp sii Insurenc¢�r a certiI of copv thereof(Sea. TYPE I
3800, Lab. d ED S'F/' T/ _,n�G�
Policy No, i, pan,— n �✓ ` f
❑ cernredy1 Pv is v furnished. LENGTH
❑ Ce Rifted-4 inspection division. ,.
Applicant FEE SUMMARY
CE FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred tlo)- (�
lars($100)or less.i VALUATION SJ
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.
Data Applicant _
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, PERMIT FEE X-f-/XC-
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 rove DATE OF APPLICATION
I certify that have rea this application and state that the above internal /
tion is correct, 1 agree to Omply with all city and county ordinances and sP / �/�Jam'
store laws Rout g to bui , construction, and haraby authorize rmnalve )
lalive5 of this IW to an upon the above mentioned property for inspection
purposes.
(We) agree to indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against I' "ti figments,costs and expenses whim may in any way accrue
,t against s conseque he granting of this permit.
�,' neNr¢ pplicent/COnRec[or
Data ��7/�S__
C
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