R 3746 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R' 3746
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 1180 DAVSOF WORK ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION
BUILDING ADDRESS BUILDING USE
10480 Ainswort}1 Drive RESIDENTIAL XX COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME Lee FIRE COVERING A
AREA CLASS
ADDREQQ same EXISTING ROOF COVERING
PHONE 408=738-4715 NUMBER OF EXISTING COVERINGS nnP
CONTRACTOR'S
NAMF Heritage Roofing Inc. TO BE REMOVED Iry TO BE RETAINED
TYPE OF ROOF COVERING
ADDRESS
CITY g ZIP987 First St. Suite P Livermore 94550 EXISTING
PHONF 510-447-7508 BUILT-UP ROOF
LICENSE / ASPHALT SHINGLES �'� a
NUMBER tp 9s? !6 WOOD SHAKES. ✓W*,? X X
LI CENSED CONTRACTORS DECLARATION Ii �'
I hereby affirm that I am licensee under provision,of Chapter 8(common �/h ,A
cino It swoon 7000) of Division of the Business and rDfef.ion.C WOOD SHINGLES 77
and my"am"Is Ire} ibforta sne affect. GLFC
License Cie. ll i4 Lit.Number
Data 1/1A/46 C.mraclot ti� OTHER (SPECIFY) /,I,-
DER OWNERBUILDER DECL A ION V
I hereby affirm that I am exempt from the Contractors License Law for
the following reason. (Sec. 7031.5, Business and Professions Code: Any city PROPOSED
or county which requires a permit to construct, alter, Improve,eemollsb,or
,.poll any structure,prior to its issuance,also requires the ePpilc.nt for such BUILT-UP ROOF
P.=,to file s agreed st return t that he a licensee pursuant to the provisions
of the Contractor's License Lew (Chapter 9 (commencing h Section 7000)
•
from Division 3 of the basis Business and alleged xem tion.)m abet. a exempt there ASPHALT SHINGLES
from sne the basis fear the alleged axampn Pn. Any vl a on of Section
7031.8 by any applicant for a permit subjects he-altpljcan t a civil Daoalty
01 not more that five hundred dollars($5001.K / WOOD SHAKES
❑ I,as owner of the property, or mV empl e'swv`Ith W ge e,their sole
compensation,will dot opn,.' a eruct ,R n d�d or offered
for sale ISac 7044, unes�antl Pr...eswnS C a t clear'.License WOOD SHINGLES
Law does not apply [ ennwner of property w a ins Oves mare on,
and sutra does such wo himself or Iou I ow um ov.0.1 wded that Monier Villa
such improvements ere an o o ad or �er If, however, the OTHER (SPECIFY)
building or imbrovem wl thi s year of-compiation, the owner
builtlsr will have Me butyl of I Ing tIt he did not build or improve for I Lite the
purpose of,own PROVIDE I.C.B.O. REPORT NO. rr 1093
❑ I, , owns f the operfg�clun44, convecting with licensed
con V: The to construct ice se Law (Sac. t app Business one Professions
coee: The Contractor's License Lew does not apply to an Owner of property PROVIDE Iii INSTALLATION SPECS.
who builds or improve.thereun and who contracts for such projects with a
contracto,ls)licensed Pursuant titt the Contractor'.License Law.
❑ I am exempt under Sec &P.C.for this
reason APPLICATION DATE VALUATION PERMIT FEE
Own., Data
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I have a certificate of consent to self insure,or a care Jan/Feb 96 18000
bbcate of Workers'Compensation Insurance,or a certified copy thereof(Sec
3800,Leb Seismic Pollcv NO.�6Fnpenv AtP FimA
4RCartrfistl copy M1sraby furor a Total
C.Infl d CO Wlth J y Inspection division
Applmant IF
C TIFICATE OF EXEMPTION FROM WORKERS' N `, ❑ PERMIT AUTHORIZATION I DATE
COMPENSATION INSURANCE /]/r/rJL��
(This section need not be completed a the work f a for one hundred r it is f l
lots(9100)or Ies..)
I ceI she that m the Performance 01 the work for which this permit is any muse, ,hall 'C employ ion psrwn In any manner to n to become subject
to the Worker,'Compensation Laws of California,
Data NT: If, ��
NOTICE should APPLICANT: o he W rke making' this Compensation provision.of Ex of th,
you should become subject i h c Workers'Compensation nsr this of the
Labor Code,you must forthwith comply with such provisions or this permit All roofs shall be inspected riort0 an roofln material b In
.hall be aeamea revoked. P P Y g 9
I certify that I have read this application and state that the above Informs Installs I a roof is Installed without first obtaining an
lion is correct. 1 agree to comply with all city and county ordin nc"and In8 eC O l e fee t0 f ove all new materials for Ins
state laws relating to building construction, and hereby euthon:e represao- p g Inspection
tat
ves of this city to enter upon the sbovemenboned property for inspection
Purp Wan.
IWt liabilities,agree uva, intlemmfy sne xpe es whi h the City of ay accmo
sgslmt ld ly )uegmenss,coax Intl expenses f this may in.any way accrue -SI"ATURE OF APPLICANT DATE
sW imt Sold City in conuquanu of the granting of this permit.
'• PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY