R-0174 PERMIT
APPLICATION FOR 'CITY OF CUPERTINO NUMBER R- O1 /�
1 `t
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITH N 180 DAYS PPISSUANCE DAYS OF PERMIT
FROM LAST CALLED
^�
BUILDING
//ADDRESS !� /'J BUILDING USE
S
83c0 �r »L(_I Iii l�r� 0PTS RESIDENTIAL COMMERCIAL OTHER
OWNER'S
ROOF
NAME
RuSrl,y) SjP%QV2A SILVC- STER FIREARDOUS COVERING
AREA CLASS
ADDRESS g-3(o Sor STG'ZLl1JC-1 "2c) . EXISTING ROOF COVERING
PHONE 4U8 257 -ISIIo' 'GQK. �I15 969-5825 NUMBER OF EXISTING-COVERINGS
CONTRACTOR'S TO BE REMOVED TO BE RETAINED f
NAME TYPE OF ROOF COVERING
ADDSS,
CITv 8RE,ZIP EXISTING
PHONE BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER ✓
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under a Business
of charier s(nommen- WOOD SH ING LES
ting with Section 7000)force
Division 3 of ffia Business antl Professions Code,
and my license is in Lull force and effect.
License Class Lic.Number
Date Contractor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm the, I am exempt from the Contractor', License Law for PROPOSED �a
the following reason. (Sec. 7031.5, Business and Professions Code: Any city '
or
county which requires a permit to construct, alter, improve, demolish,or
I repany structure, prior to its issaanae also reauires the applicant for suchgUl LT-UP ROOF
Fermi t to Is a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3of the Business and Professions Code)or at he is exempt mere ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
7031.5 by any,applicant for a permit Subjects the applicant to a civil penally '
r no ora the,five hundred di($500).): WOOD SHAKES
,$IJ Im, ps owner of the property, o,my employees with wages a5 their sole
incantation,will do the work, andthe structure is not intended or offered
for sale (Sec. 7044, Business and Professions Code: The Contractor's License WOOD SHINGLES
Law does not apply to an owner OI 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) 5F•+`�
building or improvement is sold within One year Of completion, the owner lie
builder will have the burden Of proving that he did not build or improve to;
purpose of Sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, a5
owner of the property, am exclusively contracting with licensed
central, to construct the project (Sec. 7044, Business and Professions
Code: TheContractor's License Law does not apply to an owner of property 7,. PROVIDEMFGR.-INSTALLATIONSPECS.
who builds or improves thereon, and who contracts for such projects with a
contractors)licensed pursuant to the Contractor's License Law.
L] I am exempt ander Sec. ,B.&P.C.for this
reason FASTENER
Owner Date 4
WORKERS COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to suit.insure,or a cer. TYPE
t ificmo of Workers' Compensation Insurance,or a certified copy thereof(Sec.
3800, Lab.C,),
Policy No. Company
D Certified copy is hereby furnished, LENGTH—""'.
❑ Certified copy is Hired withthe city inspection division,
Applicant 1
CERTIFICATE' FEE SUMMARY
OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred tlol
las($100)or loss.) - VALUATION
I certify that in ,he perform Wet the work for which this permit is 1
issued, I shall of employ any parson �y y to be subject gyp}- ,{("`�
1.Dteo�l A tl tic news f7/f.f/f� �v � V V � �� � ,may
PP <<
NC IC TO APPLICANT: If, after sterling this Certificate of Exemption. - PERMIT FEE d�
you should become subject to the Workers' Compensation provisions of the
:hell a pointedae must forthwith comply with such provisions or this perms , DATE OF APPLICATION
I certify that 1 have read this application and state that the above informa
Had isr ect. I agree to comply with all city and county ordinances and
State lawsrelating to building construction, and hereby authorize represen.
tatives of this city to enter upon the above mentioned property for inspection
purposes.
(We) agree to a indemnify and keep harmless the City of Cupertino PERMIT VALIDATION
against liabilities,judgments,costs and expenses which may in any way accrue
against said
sill in/nconsogs.re^/c@l he ran,in f,his permit. p
y y IZI fY"I v v •/YF a74 /T G/O S
�) Siena a-of ApplitiondCantra tar Data X p
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