R-3918 APPLICATION FOR . PERMIT R_ 3 918
s CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS2 ``__� BUILDING USE
6 n1r L RESIDENTIAEy— COMMERCIAL OTHER
OWNER'S
� HAZARDOUS ROOF
NAME FIRE 1-10 CCLASS
OVERING
AREADDRESS ,q' A EXISTING ROOF COVERIN
6 G
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'
NAME ;lP�/ r/�of tt-e�j//1
TO BE REMOVED TO BE RETAINED
`!� f /� �cI �,f p (�� TYPE OF ROOF COVERING
CARD
ADDRESS
(� fir' #0� ! T 5 C `+/� 7'�� `-�7 / EXISTING
PHONE C �1� 7- BUILT-UP ROOF
LICENSE ("LK— ASPHALT SHINGLES
NUMBER 7
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 withhereSection t 7000 I of licensed Ander a Busines of Chapoto 8(cpmm•m
cine with seisi T000)force
and en 5 of Me apanm end Professlom Co'.. WOOD SHINGLES
enw my license is In full Lorca mw effect. '
License Cie. Lia Number
Dan Contacnr OTHER (SPECIFY)
OWNER-BUILDER DECLARATION n r
Husby •Herm that . 731.5,+ Opm the Contractor'sssiLicence Lew for PROPOSED '�
one lollowtomo lw icon. iSec. permit, Business and Professions Code: Any city r
re air any which requires a Permit to c, also re alter, he aper,demorfn,Or
Perm any tee a sign prior t0 in issuance,h ei elft sed Aur that to
l0.taco BUILT-UP ROOF
Permit to file a signed Li ense Lastatement that he if licensed(commencing
to[h•tion provision.
of the Contractor's s Lienee Law(Chapter io s (comm rThat wi to Section]000)
fromDivision 0 01 he Business ens Professions tion. or That he it n of S ctio ASPHALT SHINGLES
from ane an basis for M• perms exemption. Any violation of Section
of not by any applicant re a vermis subjects+M1e eppllcant to a civil Penalty
of not mon that ova hundred dollars r my em WOOD SHAKES
❑ I.a owner of the property,a or he employees with wanes as Meir sola
for sets (Sec.
will do Ma work,and Me structure is not intended offLicered
nse
fora o Isec. apply to an o and f property
Code: Therimproves
Contractor's License WOOD SHINGLES
Lew whet not such to an owner o1 o•r[y woo n em to improves thereon,
and who dove such work not intended
or edorthrough his own employees,If. howevetl that
such improvement are not old within
or offered for sale. If, however,owner OTHER (SPECIFY)
building i improvement t e bur i sold within o e year of completion, p owner.
builder will hrva the burden of proving that he wee not build or improve for
Purposeof sole.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, s owner of the property, am exclusively contracting with licensed
contractors to construct Me proles[ (Sec. J04a, Bnsinns end Professions
code: The Contractor'sLic•nseLaw does not apply tOanOwnerOfproperty PROVIDE III INSTALLATION SPECS.
who build. of improves thereon,and who contracts for such project.witn e
contractor(s)licensed Pursuant to the Contractors License Lew.
❑ Am e.amP+ ,neer s.a. ,B S .suthis
i.
Intort APPLICATION DATE VALUATION PERMIT FEE
Owner Date
WORKERS'COMPENSATION DECLARATION PAID
1 Building I Ire! lI ,
hereby affirm met I have a certificate of consent to selbinsure,Prater P I D -
tiiiceta of Workers Compensation Insurance,or a certified copy thereof ISec V $QISmiC
5800, No. C.). r�
Policy TIA
Certified
Company Prig 1
eCertified copy it hereby furnished. V Total
Certified copy it filed with M:city inspection division. 190
APPIic•nt ! / 'Ip V
CERTIFICATE OF EXEMPTION FROM WORKERS' N C ❑ F GLJ IT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if.the permit is for one hundred dol.
lar.($100)or lesa.)
I cattily In at in Ma performance of the work for which this permit is \ /(
issued, I Mall not employ Any person in any manner so at to become subject
to the Workers Compensation "we of California.
Date Applicant
NOTICE TO APPLICANT: 11, •iter making this Certificate of Exemption,
You shoo Id become subject to the Workers' Compensation Provisions of the
Labor Coda, you must forthwith comply with such provisions or this permit All roofs shall be ins acted prior an roofing matorialbein
Mall be deemw evoked. P P Y 9 g
I certify that 1 have read Mit application and state that the above Inlorma. Installed. If a roof IS Installed without first obtaining an
Pon is correct. I spm to comply with all city and county ordinances and inspection,I to remove all new materials for In eCtIOM1
In
ateoe laws relating to building construction, and hereby authorize repredem P
t•tives of this city to enter upon the above mentioned property for apaotion '
purpose.. 5
(We) agree to save, indemnify and keep harmless Me City of Cupertino
against liabilities,judgment$,cons and expenses which may in any way Accrue
against sold city in consequence of the granting of mit Permit. URE OF APPLICANT ATE
4PPRE-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