R-3985 PERMIT 3985APPLICATION FOR CITY OF CUPERTINO NUMBER R
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMITPERMIT EXPIRES IF
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERM T NOT
OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S ,
HAZARDOUSROOF
NAME FIRE —�— COVERING
AREA CLASS
ADDRESS q. c i EXISTING ROOF COVERING
PHONE\L_6D e�J 2L "-7 6 7,0 NUMBER OF EXISTING COVERINGS
CONTRALTO S
TO BE REMOVED TO BE RETAINED
NAME 2 TYPE OF ROOF COVERING
ADTDV RE8f SS / 7 O q/ 0.
G/ EXISTING
PHONE Ir/IL/ Sey' ' O 6 '62 BUILT-UP ROOF
LICENSE /.> b ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LIC ENSED CONTRACTORS under DECLARATION
1 withherebyS affirm that I of licensed under Provisions of Chapter
o Prov g(commeo-
ing with Sectile .L-A of Division 3 0l the Business ma Prot s'o cone. WOOD SHINGLES
and my Ilcm(le.L-A
sena and enact 4 j
License `.E Con racto'r OTHER (SPECIFY)
Oat I mBUILDER DE the Contractor'.
ont
I haowin affirm that em deempt M1Lm the CLnfrassio s License Lew toy PROPOSED
the county
following niton. (Sec, permit Business and Professions Code: Any city
re e°V ny tructhich re.prresior
• permit t0 issuance.els oct.re sins, im Prop°,tlamortn,°I
perms any ale a sign,prior fo an that hi also require theapplicantthe p for such BUILT-UP ROOF
permit to fila apnea License
Law that he is licensed(commencing
it the provision{
of Dia Contractor's oft Licame Lew (hepta. % Ico e)or that wi to exempt 7000)
th...
from
Division h 01 the Business and Proalleged
exem tion. or that he is n of S ctio ASPHALT SHINGLES
from end the bels for the alleed •u•mpts th Any violation of Section
7f031 no, by any tfive hu for°permit subjects the applicant to a civil penalty
Oi not mon that live nomad property,
r my employees.1: WOOD SHAKES
❑ I, ti hwne of one Pro rk,y,or he rwith were as r offered
fomp..(tic. 1 do Nd work,and ins{ Co re is not intended°r License WOOD SHINGLES
for sal. (Bac. apply Beano{andProfessionsfrarty Code: The Co.tnno:s License....
LOW who
not apply to an Owner of through his
-no nudes to ees,provided
In ded that
and wno doe{such work not int or ed or ones own(male. It,provided foam
ui: ng or improv a His innmatl o one
year
for ale. It, however,othe OTHER (SPECIFY)
such
i improvement the b r is tole within th • e di hl completion,on. mne own err
Purdeepose,
will have the.urea. of)ronin)Ne he did not Huila or improve 1°r
°°rP°'°°s own PROVIDE I.C.B.O. REPORT NO.
❑ I, r. owner construct
the property, am(Sec.
7exclusively4, connection with r lemon&
code ton to tractor's the project les not
Business an owner
and Prpof roperts
Code TM1e or improve$thereLicense Lawand who co tracts fol such Pr acts with PROVIDE MFGR. INSTALLATION SPECS.
-no bud&f °r imbed pursuant
su nt t mtl who actors Li for a La Projects wain e
contractorl
am licensed under enc[O ln0 COntIOC[0I's License Law.
❑ I em ev(en)t unser Sec. ,B.&P.C.for this
reason APPLICATION DATE VALUATION PERMIT FEE
Owner Data
—
WORKERS'COMPENSATION DECLARATION P A I D Building
I hereby elfitm [n [ a�tiliceme of consent to self insure,or*Car
fifecata hl WorYkeeri F-Mfur o a iiia•(copy Thereof(Seo Seismic 4^
3800, R 17 �qviro
—�W—
Polic No.� om n^i ^ �/� MA
Cat Hied cop eby f toed. + Total
Car I.I{t raw fn:cityQoe_ fi ya!Wsion. CI
Ty
A°Dlecent 1 4n��J V
CERTIFIC TE OF EXEMPT ON ROM WORKERS' N.C. PE fAtlryORIZATION DATE
COMPENSATION completed
INSURANCE
(This{action need not be completed it the permit is ter one hundred tlob
man($1004.r or that
i
I ceIih fnet in m° performance of the work for which eco permit it
sou°e, I shell not employ any Peron in any manner so as to become tubj.Ct
to the Workers'Compensation pyic Lows of California.
Date AT: If,
NOTICE should
APPLICANT: . sitar Work.,.'
this Compensation
Certificate of Exemption
You .Houle become object to Ina Workan'Compen(tion Drovi{iono of Na
Labor coda, you must forthwith comply with wcn provision.or his permit All roofs shall be inspected prior to any roofing material being
{hall be aaame l revoked.
I certify that I have rand this application and{ten that the above Informs Installed. If a roof is Installed without first obtaining an
Tom Is correct. I nor°° to co tons weh all city and county ordinance{and Inspection,I a nee to remove all new materials for Inspection
stat. lent relating to builtliIT eonftrucnon, end hereby authorize reDe(eo-
tetivet Of this city to enter upon the above mentioned property for inspection
pur(We) /
(We) .brae to (vat indemnity end keep harmless the City of CuPotino �Q9--3p� 31174
.gain abiDe,judgments,costs and expense{which may In any way a«rue
.wins[(id CITY in consequence of the granting of this permit. SIGNATUM OF 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
OFFICE COPY _