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R-0187 Y PERMIT R_ 0187 APPLICATION FOR CITY OF CUPERTINO NUMBER Q REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION PERMIT EXPIRES IF WORK IS NOT STARTED x WITHIN DAYSOFPERMIT ISSUANCE OR 180 DAYSSFROM LL Sl INSPECTION.CALLED I CTION. BUILDING ADDRESS BUILDING USE G/ / _ RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS ROOF NAME 7©/CA FIRE COVERING nA AREA - CLASS I' ADDRESS.'115 ll C / ! /7AO EXISTING ROOF COVERING PHONE. -" a ✓ .T' Q - NUMBER OF EXISTING COVERINGS 9-,JI•. CONTRACTOR'S - ✓� ��F/�/ U/C�,S /J d� TO BE REMOVED Y' TO BE RETAINED NAME C7 _X/� C--� TYPE OF ROOF COVERING ADDRESS CITY&ZIP $-LL �/V.�dy7L�. � ^/•� �•� EXISTING `n'"•.'' PHONE BUILT-UP ROOF - /�/^ �U/Q LICENSE /�/ _ - ASPHALL-T SHINGLES NUMBER / c e:• Ks"'k.-'lie `-:'" WOOD SHAKES LICENSED CONTRACTORS under DECLARATION hereby ctaffirmthat I licensed under prows ons of Chapter e s(coons Code, WOOD SHINGLES t ;'j ' ung -it Section )��((((1a1a00)�s i 'v i on 3 of iM1e Business Professions Code, and my recuse is:1rr 10 no effect Ip'17/ f ' License Cie. ``r✓J L'c Number EE `1 s Date conna¢[o��I�IyCP OTHER5(SP.ECIFY) • w T R-BUILDER DECLA ATI y. I hereby affirm mat a mpl from the contractors license Law for PROPOSED . the following r (Sec. )031.5, Business and Professions Code: Any city linty which s requires a permit to construct, alter, improve, dem Olisll or repay any structure,prior to its issuance,also requires the applicant for supM1 IBUI LT-UPijROOF 4. permit to fila a signed stale rain,that he is licensad pursuant to the provisions of Ne Contractor's License Law(Chapter 9 (commencing with Section 7000) •' of Division 3 of the Business and Professions Code)or that he is exempt there ASPHALT SHINGLES from and lbe bass for the alleged exemp 1 Any violation of Section 1 Ile7031 5 by any appl cant ;he perm t subjects the applicant to a civil penalty - ,;I of not more that five hundred dollars(5500).). WOOD SHAKES ✓ n/c�C ❑ I,as owner of the properl,or or, employees with wages as their sole f, compensation,or 11 do the work, and the structure is not intended or offered WOOD SHINGLES for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, J antl who does such work himself or through his own employees,provided that xtr lithimme provents are not intended or offered for sale, If, however, the OTHERT(SPECIFY) iy bulldi ng 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 sale.) ❑ 1, as Owner of the property, am exclusively contracting with licensed PROVIDE I.C.B.O. REPORT NO. contractors to c mn.el the project (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner 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 under Sec. - &P.C.for this r� r-'. FASTENER:��r} :owner _ ,,Data;_.. , WORKERS'COMPENSATION DECLARATION 1 hereby affirm that I have a certificate of consent to sell insure,oro car. TYPE 4I 19, rf"to of.INor kers' Com o t on Insurance, r certified copy thereof(Sec 3800-L b 3 '� T�.:� ,.y l 'Policy Ns Ys mU C. ,eSA5Z4 Il Ce t f e M1erry�fu rn M1gp _ ... -vision. _ « S/ art L s i lh m ty spacti v s o 'LENGTH App call' / '�' FEE SUMMARY CE IFIC MPTI5NL OM WORKERS' COMPENSATION I URANCE t '. •�I (This section need not be completed if the permit is for one hundred tlol- lots(5100)or Ims.) VALUATION e 6 I certify the, in ,he performance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to become subject to ine Workers'Compensation Laws of California. Dote Applicant '//, NOTICE TO APPLICANT: o hear making his Certificate to of Exemption, PERMIT FEE YY•J TTT you should became subject to IM1e Workers'h such provisions ns or a the mit Labor plan ed r must forthwith comply with such prOviaioni OI rose permit shall be planned revoked. >, DATE OF APPLICATION — ].certify.that 1-nave nold this ej5d t 1-and sl to th t the ab fg .— s 7 Iloli 's torsed -I'a9�ee tc comply tri We ty t(coli lhr o i I _ es nd` ^' "—'t •1^ -_ ,,1 ..•t, .. •-a -•. ,�, :.,TM �- state laws relating to building construction, and hereby authorize represen- / .f tatives of this city to enter upon the above mentioned property for impaction G.l purposes (Wea ,p s da)nny a d keep harmless,me city of Cupertino q, PIrRMIT VALIDATION ages �ib.`jjl,Oas,ju va oOt ash d expenses wnicn may in any way accrue nst Ci se ce tha gtenliP f-this permit am r¢of App 4n' c. REQUIRED PRE-INSPECTION IN-PROCESS INSPECT{ON FINAL INSPECTION INSPECTIONS INSPECTOR DATE INSPECTOR DATE'~ INSPECTOR DATE NOTE:-- -OSHA APPROVED ACCESS TO ROOF SHALL BEPROVIDED FOR INSPECTION INSPECTOR COPY