R-3947 APPLICATION FOR PERMIT Ree 3947
r CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 VETHIN 180 DAYS OF P RMT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS/J BUILDING USE
41 RESIDENTIAL COMMERCIAL OTHER
OWNER'S /)
NAME //.P �� FIRE
HAZARDOUSW
ROOF
COVERING
�? AREA CLASS
ADDRESSy EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS 2—
CONTRACTOR'S
TO BE REMOVED Z TO BE RETAINED
NAMEc.71oL�GLtr� �� TYPE OF ROOF COVERING
CIADDRESS
Y&Zib "Is" y i �a' y+ik*�c/ V EXISTING
u q4a jF46.
PHONE(��_,rl, `lam BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER C.. G
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I of Incense,under a Business
of Chapter .Icommee,
ang Wltn Section Jolwl or DlYifion a or en. Bu.In...ena P.PM1..ihn.toes. WOOD SHINGLES
and my Ilwnu it Iy,ruLLt a ane affect �+ /
Dal. Clm G� tl C. Number !O
Dat. OWNER-BUILDER cDECLtRATI&N;="` OTHER (SPECIFY)
maxeptf OE the Cont N
I hereby arum mal Ito exempt trim ss, dPntra<to:. License Any
for PROPOSED
the fon county
n0/cure. ISec. permit to construct.n and Plter, i prr.Code: Anv ci
re cru my wnicn homier apes i it to c.( .Ines imp.hare, ri
.emir.tsar lsu trio/to in khat he al"onPui/e{the P est to/such BUILT-UP ROOF
permit 10 file a signed'. Li statement Levy (ban he is licensee to Ina t oovi{lonf
of Me Corr3 of the Lienee Levy ICf.slio oto)or that with Section O to G
of Division of the Business and P/orassto f Code)or.net he h e=.m t r .e" ASPHALTl� l
from and nn. basis for the alleg•C exa Psion. Any viobtio of S n p
)0]1.5 by any applicant for a Permit sub n the applicant to e c 'I
or nm more met Ree hundred ehuas Isco LI: ODD SHAKES
QL ti Pwn.il 'd the property,o.1. mPIPy.I.wi,M1 , nd ., r. l! 1995
Pe.(So.. iu Business Ina work,Ina the s acture is not intone otter \^\j_,(y/`) ODD%iLl
foe eel•ISec. TOAA, tooand f proper, Code:: TM1e Con c :f Lice '
Law whet not apply to an Owno Or Pro°ert is o buil o/i p are{m��������pppppi ,
and wM10 does such work himself or through is own am ,prov id ✓ y
such improvements are no, intended or of ere. for h V, THE61(' UCI Y)iKIINU
building or improvement is sola within on year of c tion, t
buil ear will have the burden of proving that a did not but a for e
°°'P°'a O1ae1w ROVIDE I.C.B.O. REPORT NO.
❑ I, as owner OI [ns, Property, a •clue sly contracti wim licensed
Contac tors to construct the Project (Sec. 70 , Business, a d Profvtio
Cody The Contractors License Law does..Iso to.nowner of try pROVIDEMFGR. INSTALLATIONSPECS.
who build. or improve. mer.un, and Who con V.cu I•cts wim a
contractor(5)
licensed pursuant no the Contractor'.License Lew.
❑ I em .=atopt undo. sec. ,B.aP.c.for this
reason APPLICATION DATE VALUATION PERM F E
Owner Data
WORKERS'COMPENSATION DECLARATION f Building
I hereby affirm [ns,[ I nave i n Insurance,
, content to Copy Cher o /�0�
3800, of Workers'Compensation Inwranca,or certified copy thereof ISec. YE 1' H Seismic
Policy
No.Labk)-�5C/p /] .0/J � _/ •+ J
POI icy C.,rft GC y C'�Q•C6C61e-" Jaime
Coni tied Copy I.hereby fui,rn; ad. Total
cotif. P rued n the city.'IA,pectiOn plvlgton
Applicant LL CCf(OO//,,/�,� /l
CERTIF CATE OF EXEMPTION FROM WORKERS' N D ❑ PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the Parmh is for one hundred mI" �/ (
I.rs IS1I ll not
1 cvtify that in m• performance of mo work for which this permit is {/
i..0
I {hall not employCompensation
any parrots any manner to at to become Subject
to V. Workari Compenution Lam of CPlilorni.�n
Data Applicant
NOTICE should
APPLICANT: If, after making oh'n Carnilicate of Exemption,
you mould become uhf act to the Work.,. Compensation provisions of the
Labor Code, you must forthwith comply with such Provision,or this permit
shell be Poll rvokad.
All roofsshall be Inspected pAortoany roofing material being
r
I certify mat I have read this application and{tan that the above Informs. installed. If a roof IS Installed without first obtaining an
.ion is collect. 1 agree ,o comply wim all city and county ordinances and IDSA@Cti ,I ogle new materials for inspection
.......
bt1 la W. Salting to building tons ruction, and hereby auth.nit. ..preesm
relives of this city to onto,upon me above mentioned property lot Inspection
Purposes, Zr
(We) .gra• to Save, indemnify and keep harmless the City of Cupertino
against liabilities,judgments,cost,and expenses which may to any way accrue
against said City in consequence of the granting or this pe/mit. SIGNATUR F APPLICANT 'DATE
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
T OFFICE COPY -