R 3990ift
7
OFFICE COPY ...
PERMIT R_'3990
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT PERMIT
(408) 252-4505 EXT. 228 IE80 DAYSOF WORK
OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS \^, n 1X
-1_q--L \
- BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
Ow,sS
HAZARDOUS ROOF
NAM -
AFIRE COVERING
REA CLASS t
-
EXISTING ROOF COVERING
ADDRESS.
.
NUMBER OF EXISTING COVERINGS
�yr�Q
"1 '
I O /�
PH& l
CONTR!TOPAO
r
TO BE REMOVED TO BE RETAINED
NAM
TYPE OF ROOF COVERING
�
CIITY St Z10
- i)
EXISTING
�� � 1�I'IJ
I
`
BUILT-UP ROOF
PHONE 1
LICENSE
r"7 '7TT�—� _
ASPHALT SHINGLES
NUMBER
C� �� VZJ
WOOD SHAKES C
LICENSED CONTRACTORS DECLARATION
1 hereby alfirm that I am Iicrosad under provision, of Chapter 9 Icommem
ling with Sacti n T, Olvislon 3 of the Bus n .mos Cotle,
and mY Ilans s n f end effect. T
License eel u Numbers V
WOOD SHINGLES
ry
CLit.ontractor
OTHER(SPE8140
10 -BUILDER DECLAR i
f r
I hereby •ffbm met 1 am ...mpt from the Contralto:. License esacAny
the following reon. (S. 7031.5, Business and Professions Code: ny cl
PROPOSED pV� 17 1996
or county which requires a permit to c struct, alter, Improve, demolish,or
rapeany structure, prior to Its asuane Iso requbes the applicant for such
permit to file a signed at•temmt that h. a Ictimed pursuant to the provlsion
BUILT& ROOF
I,t'i1
If ma Contractor) Licend
bpn I<ommencing with Section 70001
Vi VUYCrI l IIV V
of Division 3 of the Businfesu s Code) or that he 11 e.empt mere.
end Me bola for u• tion. Any violation o1 Section7031.5byanyepplli1
ASPHALT SHINGLESfrom
theapplicant to a civil penalty
of not more shot nXdh
Nip aiii-qI.
palWOOD
es ownerr my employees with their
SHAKES
wapas o
solecompensationwilQ-the structure is not intended or offeredyy00D
ole (Sac. 7004ofessions Code: The Contractor's LicenseLaw
SHINGLESfor
tldes oat applproperty who builds or impr Oves thereon,
and who tloes suchm" I or through his Own employees, provided that
such Improvmen0 •raicoi interia d Or offered for tele. If, however,
the
building or improvement is sold within one year of completion, the owner
OTHER (SPECIFY)
build., will have the burden of proving that he did not build or improve for
purpo...1 salPROVIDE
❑ 1, at owner of the property, em a.clu.woly contracting with licensed
I.C.B.O. REPORT NO.
contractors to construct the project (Sec. 7044, Business and Profession,
Code The Contractor'. License Law does not apply to an owner of property
pROVIDEMFGR.INSTALLATIONSPECS.
who builds or improves thereon, and who contracts for such projects with a
contractor(.) licensed pursuant to the Contractor's License Lew.
❑ I am exempt under Sac.,8.6P.C. for this
own
APPLICATION DATE
VALUATION
PERMIT
F E
Owher Data
WORKERS' COMPENSATION DECLARATION
Building /
I hereby affirm that I have • certificate of ci nu , to Olf-inWre, pr • car
ei' ` erypion Inwrenc•, or. c.rara yen real Isec.
3800,Vl
moo9111
I
1 1
1111
eiamic
PollspGis CjpI�rTPe
I _I
I�1r�
1
'
cop . hereb�furnishe .TOtal
's
Ijled pl(h mP)<Ity imvecHon division.
APDIiG01 A. �'/Y/ �+
PERMIT AUTHORIZATION
DATE
CERTIF ATE EX�WORKERS' N `,
COMPENSATION INSURANCE
(This section nod not be completed if the permit is for no hu red dots
los ($100) or In,.)
1certify that in the performance o1 me work for which this permit is
iwued, I shell not employ any person In any manner so as to become subject
to the Workers' Compensation Law. of California.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of E.Ishi n,
you should become subject to the Workers' Compensation provision of the
Labor Coda, you must forthwith comply with such provision or this permit
All roofsshall be Inspected roofing material being
Lebo be domed revoked.
priortoany
Icertify that I have read this application and state that the above informa.
Installed. If a roof is installed without first obtaining an
stat is laws correct. 1 with .0 city end
to end co noes and
orillnwpe. end
lewd
Inspection, I agree to rIns actio l a ree to r�ve all new materials fol ins ect nail new materialsfo Ins ect n.
p g p
ng con
.tete relating to building construction, entl hereby
to authoriie
tetivea of LD city to enter upon the above-mentioned property for Inspection
1 f
purposes.
(Wel agree to soya, indemnify and keep harmless the City of Cupertino
.paint liabilities, judgments, cons and expenses which may In any Wry •sprue
SIGNATURE E OF
APP CANT E
against sold City in consequence 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 ...