R-3845 PERMIT R_ 384 5
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDINGADDRESSBUILDING USE
I01I'A , rwo D — jOc�OO vi em RESIDENTIAL `/ COMMERCIAL OTHER
OWNER'S 1 /V� y
NAME Goh(�o I'fUWI[1eem C3h1 FIREHAZ
ROOF A
COVERING
AREA o CLASS
ADDRESS(1'ry q The A1umP� tv ��0 EXISTING ROOF COVERING
PHONE Nog) {� Q NUMBER OF EXISTING COVERINGS
CONTRACTOR'S - �S
NAME `TgOy(v?r RooFLh� ,( c \ 70 BE REMOVE TYPE OF ROOF COVERING
D
CITY&ZIP Jd,47 S. 7 �} S��11 �.J 11d EXISTING
Q'� —7S� � BUILT-UP ROOF
PHONE GOR)
LICENSEI76 - ASPHALT SHINGLES
NUMBER
WOOD SHA
LI LENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ii<ansed under provisions of Chapter 9(=ommm
cin,with Section 7000) of Division 3 or the Business and Professions Coda, WOOD SHIN LES
and my license i in force ane affect.
Data �c1-s1 Li=.Nume._Ca� OTHER (SPE IFY)
Data COnbKtO.
OWNE RBVILDER DELLA RATIO
1 hereby affirm that I Pm exempt from the Contractors License Lew for PROPOSED
the following neon. (SK. )031.5, Businau end Professions Cada: Any city /\r
or county whim requires a permit to construct, altar, improve, dem°Iifh,Or � "y��
npalr ary structure,prior to its issuance,also requires the applicant for such BUILT-UPR 0'F✓��
pe= to rile a signed statement that he a licensed pursuant to the Provisions \J
of the Contractor's3otBusiness
Lew ICn•asio $Code)o that wi to exempt 70001
from
Division 3 of the Blot th and Proalleged
exam tion. °r that of ti exempt more ASPHALT$ INGLES
from entl the basis t°r the alleged exempts the
Any violation L1 Section
)031.6 by any applicant re •permit subjects tea applicant to•civil penalty
PI not more that five hundred dollars(Ii m WOOD SHA ES
❑ I, ni owner of the p,. rk, a o he employees with wends as their sola
com.I. (Sec.
wip ao the work, Profess n.umwe is not intendedntrto or License WOOD SH I GLES
far lila fano. apply Business and f pro arty Code: The Convectors License
Lew does not apply ro an owner of property sena builds to ins°r Ovaf thereon,
and who don such work himself rint or ed or
fi r own employees, however,
that V f%m [,./�
such ng or improv a not intended or one
year
for sole. If, nOthevo the OTHER ISP CIFY) y W
building i improvement the burden
i sold proving
one year pi completion, the owner
builder will have the Owtlan of proving that he did not build or improve for
Ppr[3 ' .1 sale.). PROVIDE I.C. REPORT NO.
❑ 1, as P of the property, ons exclusively convecting Pr licensed
C.
: tarsThe to construct the project
aw lees. t app Business and Professions
whoa: TM1,Chest.Krord herbLicense and who owner of with
PROVIDE MFGR. INSTALLATION SPECS.
sono The
h mprovas tnereun,dna sono convect for such projects with a
contractor($)licensed punu•ni to the Contractor's License Law.
❑ 1 am exempt under Sec. ,B.&P.C.Ior this
Data
APPLICATION DATE VALUATION PERMIT FEE
o
her WORKERS'COMPENSATION DECLARATION Buildin xxxi
I hereby dhrm that I have a certificate or consent to sell insure,or a CO
till I.of Workers'Compensation lnn,) til; q hpy thereof(Sac. Seismic
3800,Leb�-1]U SLn c(N�\
Policy No. lrpehy ��i 1 G� SA Total
BCertified copy by IurnisPad. l iR G w
Grtifiay�opv 4L.1 I 1G the ' ec' di""an.
V ( 2w n bl
APPllunt V CERTIFICATE OF OF EXEMPTIO FROM WORKERS' N D ❑ E AUTHORIZATION DATE
COMPENSATION INSURANCE
IThis section need not be completed if the permit is for one hundred doL
mss Ia00f or Ia..l rtni INU�
I certify that in the pang person
o1 any
wort for services this permit if ^)Ir Ur VV
uad, shell not employ any porion in any manner to n to become subject J
to the Workari at Lew,of California.
Data APpli..nt
NOTICE TO APPLICANT: 11, attar making this Certificate of Exemption,
you should become subject to th*Workers' Compensation provisions of the
shelf cos., ed molt forthwith comply with Such P.ayiahns or this permit All roofs shall be inspected priorto any roofing material being
Lebobadeemed mustd.
I ...III, me, I have nae this application and$tete that the above inf.mr. Installed If a roof is installed without first obtaining an
,.an
is correct. I agree to comply with ell city and county ordinances and inspection,1 agree to remove all new materialsforinspectlon
star* laws relating to building construction, and hereby authorize npresem
talipes of this City t0 enter upon the above mentioned property for inspection
Our we) IL1 J
IWt liabilities,agree save, Indemnify entl keep heresies ma City at Dupe..
against sidtijudgments.cs licosts and expanses which may in my weV K=rw
' •aims said GW m=hnoapan=e of and nnminn of this permit. SIGNATURE OFAPPLICANT 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