R-3722t
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OFFICE COPY
PERMIT
R- 3722
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION
REROOF PERMIT PERMITE WORK IS NOT STARTED
(408) 252 -4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
- BUILDING USE
'y/��
5 I t
I I
RESIDENTIAL COMMERCIAL OTHER
OWNER'So
HAZARDOUS ROOF
NAME
FIRE COVERING
AREA CLASS
^ ,�
CC/�lJ,
I
EXISTING ROOF COVERING
ADDRESS
3 A
NUMBER OF EXISTING COVERINGS
PHONE
/
CONTRACTO.B;S.
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING III
NAME f�C-
ADDRESS 9�1
,
CITY & Z16
EXISTING
BUILT -UP ROOF
Dge5— 4II 4L q
PHONE
ASPHALT SHINGLE
LICENSE �Sy��l
NUMBER 11
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 noabv affirm that I am Ncanua under provisions o+ Cnaptes 9 (common
S
o
cing with section 70001 of Division 3 of me Business and Professi n Code,
WOOD $HING
antl my liana is I Iul110 .and affect. CI 1•
Li ="y Class ELF Lic. Number •J"7
i
OTHER ECIFY)
O t cDECLlof
OWNER.BUILDER DECLARA
1
1 hereby affirm that I am ...mw from the Conv.mor uq.n.. Lew for
FIR SED
the following reason. (Sec. 703 1.6, Business and Prolenio s Code: Any city
or county which requires a permit to construct. altar, Improve, demolisn.or
rap.ir env . tructure, prior to its issuance, also requires the applicant for such
BUI L ROOF
permit to file a signed statement that he is licensed pursuant to the provisions
or the Contractor's License Lew (Chapter 9 (commencing with Section 7000)
or Division 3 of the Business and Professions Code) or that he is..emot mar..
ASPHALT S GLES'
from and the basis +or the alleged ..emotion. Any violation or Section
7031.5 by any applicant for a permit subjects me applicant to a civil penalty
or not man met five hundred dollars ($500).):
WOOD SHAKES
❑ I, ss owner of tna property, or my employees with wages as their Solo
compensation, VII do me work, and the structure is not intended or offered
0)r sale (Sac. 7044, Business and Professions Code: The Contractors License
WOOD SHINGLES
Lew does not apply to an owner of property who build$ 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)
building or improvement i sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
pulp.$. Ol sale.).
PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property. a exclusively contracting with licensee
contractors t0 construct Ina project (Sec. 7044, Business and Profession$
code: The Contractor ' I License Law does not apply toan owner atproperty
PROVIDE III INSTALLATION SPECS.
wn0 builds or improves thanun, and who contracts for such project, with a
contragtor(s) licensed pursuant to the Contractor's License Law.
❑ 1 em exempt antler Sec. ,B. &P.C. for this
lesson
PPLICATI DATE
VALUATION
PERMIT FEE
Owner Date
Building
WORKERS' COMPENSATION DECLARATION
1 hereby (firm that I have a certificate of consent to self-insure, o a car
'`9�a
tiffs» of Workeri Compensation Insunn e, or a tified copy tne.eof (Seca
•Vi
, l
$eISn11C
3800. Lab., r
R
`�' �•,v
Palicv Car env CL
Car copy n n lurnis ad
( ``
�e •' �S`N)
s
Total
esofbtl < v impaction division.
_ i VUrC
Ap iCSP
PERMIT AUTHORIZATION
DATE
CERTI ICA, OF MPTION FROM WORKERS' � N.C.
c PENSATION NS URANCE
(This $action n ed Ot be completed if the permit is IOI One hundred tl01.�
are ($100) or leas.)
I certify that in the performance of the work for which this permit is
person as
sothe {nail not employ any person in any manner a0 a$ to become 4ubleCt
to the WOrkari Compensation Lew. of Celilornie.
Data Applicant
NOTICE APPLICANT: IL after making this of Eons
ofion,
i Compensation gravitons of the
ld the Compensation p
you mould become st
Labor coda, you must forthwith comply with such provisions of this permit
fort i comply
All roofs shall be inspected prior to any roofing material being
Mall be tleametl revoked.
installed. If Of la In ailed without first obtaining flat
1 certify that I have read to is apps ication and Stan mat the above inform..
Pon is correct. 1 agree to comply with .N city and county ordinances and
inspection, I e to ova all new materials for inspection.
$fete laws ratting to building construction, and hereby eutnolize repreal
'olives of this city to enter upon the above mentioned property for inspection
purposes.
/
fWs) agree to save, indemnify and keep harmless the City of Cupertino
againrt Iiebilit!", judgments, costs and expanses which may in any Way accfus
in
SIGNA E OF APPLICANT DATE
agahl.e.aid City con$eouence 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