R-0165 PERMIT
APPLICATION FOR CITY OF CUPERTINO" NUMBER R_ O165CC
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT PERMIT EXPIRES IF WORK IS NOT STARTED
✓'•:��; WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME �11(m��-Sy-� FIRE COVERING j
AREA CLASS
ADDRESS /D rove S' l"'A•�.P/L Loo-*--E EXISTING ROOF COVERING
PHONE S - -73r� NUMBER OF EXISTING COVERINGS
CONTRACTOR'S /�
Rgoel 0 TO BE REMOVED TO BE RETAINED
NAME r 1 TYPE OF ROOF COVERING
CDD&ZIP �r S' � �/SS /moi+' SH EXISTING
S'ojsf tLmS4" 757/2,
BUILT-UP ROOF
PHONE
LICENSEp ASPHALT SHINGLES
NUMBER L ✓'
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensee under provisions of Chapter 9(common
aing with Section TDUo1 of.Oivision a of the Business and Professions Code, WOOD SHINGLES
ndmlicense is�O toIL or nd effecoLc.Number 2 >o
7—
y
LiceClas DaeContractor -fe ' '_c OTHER (SPECIFY)
WNE BUILDER DECLARATION
hereby eesrm mat I a exI.S, Bufrom
the Contractor's License Law for PROPOSED
one ful.wtomo ing is I es ')0 Perm
t Business and Professions improve,
Coda: Any city county which fire,Pi permit to c. also re alter, imp row, dvmolizn,°r
per any structure,pro.e its ithat h ei also sed pursuant
theapplicanttolthept forovi such BUILT-UP ROOF
permit to fila t signed statement that he is licensed pursuant oo and tion provisions
of the Contractor's Business
Lew Koesterhapter s (commencingCode)ortat a iM1 Suction there
fromDivision hmmyBforOth andProfessionstion. a. y vtotionampt ofSmare ASPHALT SHINGLES
from antl an basis for for alleged exemption. Any violation Of Section
of no,5 by any.applicant fora permit subjects me applicant to a civil penalty /
of not more that r of the pro dollars
or my ed: WOOD SHAKES
❑ I,a of ma property. o he employees with wages as meir sole
compensation,sale (Sed,
owner
do the work, Profess structure is not intended 's offered WOOD SHINGLES
for sale (soc. apply
Business and f property
Code: The Contractor's hirers
Low does not apply o a owner°r property who builds or improves,provided
memory
and who rave such work not int of through M1iz awn r sale.
Il h.wtuee met
such ng or improv a not old Within o neared for idle. v, tothevor, teed OTHER (SPECIFY)
builder i improvement t e bur is z°Ir wimin ° e year or c mutation, me owner
builds. will neve me burden of proving that he rid not Huila or Improve for
Purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner construct
ma property, exclusively contracting an with licensed
contractors Contractor's tesu se La [ oes tap Bto need antl f Propions
rty
Code: Tne provthereon,
and who not tracts foo uch pr of with a PROVIDE MFGR. INSTALLATION SPECS.
WM1O builds o improves suant t, and who actor's Li fore La projects with d
cpnoract am licensed pursuant to the Contractor's License Law.
❑ em exempt q,Irnr sap. ,e.aP.c.mr.tms on FASTENER
owe Date
Owner WORKERS'COMPENSATION DECLARATION
I hereby affirm out I have a certificate of comentito selfinsure,or a car. TYPE /7Ae-LO JC
,iflcato Of Work - Cumpv tion Insurance,Or a certified copy thereof(Sec.
Polis Lab m `e•+/`I)<r,E
Policy No. �• IK � "
❑ Ce�gggl��rr pv.e nerebv Pi���isnee. LENGTH
❑ CeRy,�ad C' Y lad W' hyl [M1e city inspection divialan.
A°p'i`ent c FEE SUMMARY
CERTIF CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -,^e'+"'
(Thi /ion need not be completed if the permit is for one hundred dol-
lar'Ise "ass.) VALUATION
certify that in the performance of the work for which his permit is
issued 1 shall not employ any person in any manner s0 as to became subject '
to the Workers'Compensation Laws of California.
- Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, PERMIT FEE �E�/�//e . v —
You should become subject t0 the Workers' Compensation provisions of he
Labor Coda,, you must forthwith comply with such provisions or this permit
shall be deemed revoked. DATE OF APPLICATION
1 certify mai I havagree
reed this comply
with al and nand that the above noes and Han is w,rocs to
m ng with all city and ye my Ordinances and .fes
sesta saws relating 0 buildingthabovconstruction, and herebypr authorize inspection
7z �/ F �� '�•yw�
tatiyes of this city to enter upon the above mentioned property for inspection a
purposes.
Iwel agree to save, is,cots and keep es which
cry of ay accrue PERMIT VALIDATION
eg st liabilities, iud is,costs and expenses wM1ich may' any way accrue
r; gain sold in c sequence of the granting of 's peed`
gaSi o Applicant/Convecmr 1DIR6 I
RE IRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE 1INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY