R-0185PERMIT R
APPLICATION FOR CITY OF CUPERTINO ""� NUMBER ;.,:'
INSPECTION DIVISION PERMIT EXPIRATION
I- PERMIT EXPIRES IFWORK IS NOT STARTED
REROOF PERMIT
WITH N 180 DAYS OF PERMIT ISSUANCE OR
J.160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
`BUILDING USES'.
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
/
HAZARDOUS ROOF
T�`.
NAME !/ �/
FIRE COVERING
AREA CLASS
%5U/gyp �U? 9�ary
EXISTING ROOF COVERING '
ADDRESS
/
D
NUMBER OF EXISTING COVERINGS
PHONE (O /
CONTRACTOR'
�Q.
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING .
.NAME OT��/��L7 :�C -.5
ADDRESS,
CITY &ZIP ' �G 7y
EXISTING
BUILT-UP ROOF
//^^
�,7—
PHONE J�d 7
LICENSE !i/���
ASPHALT SHINGLES
NUMBER 7
,--WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
NTRA
1 hereby affirm that 1 em licensed antler provisions of CM1ap[er 9 Icommem
ing -and Proie.eions
SHINGLES
with Section 7000) of Division 3 of the Business coca.
dnamy liceme is Qful r ane effect.
.WOOD
LicaCless Lic. Number O J
Dale 33- Debtractm ,q^-0THER
.,(SPECIFY)
NBUILDER DELLA ATION)::.•
1 -hereby 'I from License Low for
1r
- affirm thatam exempt it,. contractor s
following 7031 Business Profess -ons Cotle' Any
"•.t
PROPOSED
She reason (Sec .5, and city
t -
a'
or county which requires a permit to construct, alter, improve, eemolish,or
• / '
repair any 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
of the.Contractor's License Law (Chapter 9 (commencing with Section 70001
of D'vhi0 3 of In. Bus gess and Profession, Code) or that nes exempt there
base,for
_
AS_ PHALMSHING LES -
from and the the allegeo-examption. Any violation of Sact on
7031 5 by any npplkpnt for a permit'Subjects he applicant to a Civil panel lly
' "' y!
of not more that five hundred dollars Is500).1:
:WOOD SHAKES
❑ 1, a er of the property. " my employees with wages as their sole
compensation, will do me work, and the structure is not intended or offeree
for sale (Sec. 7044, Business and Professions Code: The Contractor's License
WOOD SHINGLES
Law does not applyto an owner of property who builds or improves thereon,
dna who dove such work himno, elfint or provided that
his awn emale.
such improvements aro not i intenughded If,
o offeree for dale. If, however,
" he
ro
OTHER (SPECIFY)
ld with.
owner
improvement ie ° year of completion, me Owner
e
uilding il mve
of proving or
will peva me burden °f proving met he did not build or improve for
' t bur
pull os
°e.posaoisown
PROVIDE I.C.B.O. REPORT NO.
_ -❑' I, °s Owner [M1a rt B exclusively contracting with licensed
st he project
<ont to construct the project (Sec. Business and s
St
fPro erns
Thators
nor
r app ch
enae: Th o°improve's hereon and
PROVIDE MFGR. INSTALLATION SPECS.
tracts foal
whodoes
is with
contracts for such proje<ts with a
who onlids° [hereon, and projects
licensed ant
onmac[am l empt pursuant to me Contractor's License Law.
p Li
❑ am exempt under ear. ,B.a P.c. to, this
FASTENER
Oason
wne Data
WORKERS" COMP ENSATION DECLARATION
I hereby affirm that I have a.cartifirate of consent to self insure, or a
////�� /T� /j`/'/,��Jy�
TYPE lf/'t/ AJ ill"
a
title ate of Workers' Compensation Insurance, " certified copythereof(Saaccy,s
38011, Lab/ c—' A 7 L—�
Policy No G7C{mI
❑ cernbad Qv Is hereby turn a.
_,,�
LENGTH
a^OTertifi (�y i tiled tui h city i ecU^ aivisio .
FEE SUMMARY '1
AppOcan' !ayI
TIF( ATE O MOTION FRO ORI ERS'
COMPENSATION
complami RANCE
• (This section need not be comple[eC it [M1a permit is for one hundred dol-
erm
lace I yr
VALUATION �(
hat i
certify that in the performance Of the work for which this permit is
cerh
issued, I shell not employ any person in any manner zy az [o become subject
t° ma Workers' Compensation Laws of Califyrniann y.
Data Applicant
a
NOTICE TO APPLICANT: alter making this Certificate of Exemption,
`
—PERMIT FEE
you should becomesubject o v Compensation provisions of he
Labor Code, vou-must forthwith Complywith Such provisions or this permit
"
_
DATE OF APPLICATION
Shall be teemed rey k a.
-:.'
I co"ity that I have read this application dna state that the above informs
tion is correct. I agree to comply with all city and county ordinances and
t
State laws relating to building construction, and hereby authorize eeprazery
".
tatives of this city to enter upon the above mentioned property for inspection
PERMIT VALIDATION
purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino
againSJ.$h zl/i judgm yztz a�b ch may y way accrue
age t sa C in co eq ice of R gronYoe this permit
Signature of Applicant/Contractor fi Date
PRE -INSPECTION
IN -PROCESS IN
FINAL INSPECTION
REQUIRED
INSPECTIONS
INSPECTOR DATEINSPECTOR
DATE
INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR