R-3355 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Ree 3 3 5 5
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN ISO DAYS OF PERMIT ISSUANCE OR
.
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
O� � HAZARDOUS ROOF
NAME COVERING
ADDRESS AREA �C7 CLASS
l07�
p 1p PEXISTING ROOF COVERING
�
PHONE NUMBER OF EXISTING COVERINGS
CONTRACJ�OR'S (�
( I �_ Y/1 (,. TO BE REMOVED " TO BE RETAINED
NAME __ —C�" V•-\ TYPE OF ROOF COVERING
ADDRESS
CITY&Zlh EXISTING
PHONE L1D%— `J— �C)o BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER
WOOD SHAKES
Lm that
CONTRACTORS DECLARATION
I M1vebY affirm 7000 I of Reamed unser . Business
OI CM1 Prov B(commee,
cine with Section )000) 01 Divnlon 3 Of Me BuSlnea antl Profmlom Code,
and my license Is In full force and effect. .WOOD SH
OG�
Ey
n
�
LlOmen..s1Lic,Nub CJIContrafor OTHER (S
OWNER-BUILDER DECLARATION eIV
I hereby affirm that I m.x.mpt fw A
from me Contractor'. License Lew for PROPOSED Za .3
the following reamn. (Sec. 7031.6, OnIneSs and Profession.Code: Any city Y
Or County which requires a permit to construct, alter, Improve,dem Olifh,or ppT� 11
repr any structure, prior to In Issuance, also requires the applicant for such gUl
aLT'UP ROOF
Permit 10 M.a Signed.[.[amen[that he is licensed purni to the provisions
of the Contractor's License Lew (Chapter 9 (commencing with Section 7000) _
. of Dion 3 of the Business and Profession%Coca)or that he is exempt mere" ASPHALT SHINGLES
from end Ne basis for the allyl exemption. Any violation of section
7031.5 by any applicant for a Permit wbjeces the applicant to a civil penalty
of not or.that five hundred doll...($500).1: WOOD SHAKES-
0
I, as owner of the propl ora m
my employ.«with wages [heir l.
m _
compealon, ill do the work, and the structure is not intended or olleno
for "Ie(Sec. 7044, Business and Professions Code, The Contractor..License WOOD SHINGLES '
Lm does not apply to an owner Of property who builds or Improve thereon,
and who doe such work himself or ed .1 o Iaf own , Salovea,provided that OTHER (SPECIFY)
Such ng or improvement m ere not i ld wi ttl pr offered for ale. If, nothev [he
building ilburIS mid within one year Of of build for the owner
bulkier will have the burden of proving that he did not build Or imprOrBfor '
purpose lie..L.). PROVIDE LC.B.O..REPORT NO.
❑ I, S Owner of the ProPatY. aexclusively cOntrecting with Ilcenaed
connacton to construct the project (Sec. 7041, Business and Professions
ode: rnacon[racopraLicen„ L.wdoesnotapplytoanownerofproperty pROVIDEMFGR. INSTALLATIONSPECS.
wino build. or improve&thereon, and who contracts for such Projects with a
comrector(O licensed Pursuant to the Contractor's License Law.
❑ 1 am exempt under Sac. ,B.&P.C.for this
O
we. . Date APPLICATION DATE VALUATION PERMIT FEE
WORKERS'COMPENSATION cateDECLARATION
hereby workers'
that have i n nsuran of consent ie fel ipy the,O ager J
j 3800,00 OI Worken'Compenntion Insurance,Or a certified copy thueol Sec.
Polio, Nsido. CO. SEISMIC
P011cV No. Company
- BC.n itiait c.1Y IS fi1Z o fu I i.hed
Cots lied Copy if filed with me city infpectian division:
_
Applicant I
CERTIFICATE OF EXEMPTION FROM,WORKERSPERMIT YA [_-AT,.. U DATE
COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dol"
1.r%1$:DDf Thai.) Sip 13 1993
certify ins in me performance or the work for ebbtob this Permit is
nWeQ r ell not employ my Person In any manner So n to biome Subject ^—
tothe Workers'Compensation Laws of California.
Date ANNApplicant
If,
NOTICE TO APPLICANT:
U, Pear making this Compensation
of Exns oflPn, inTIDN DEPA Irv) ,
you Nould become sublet[ to the Workers' Compena[lon proviaiona OI the ��(� ((�� -
LabOr Code, you must forthwith comply with such provisions or this permit All typEgyllr�pOf {p Do any roof being Installed.TO
she be diesel revOkad. receive a final�are�l 0015 re will be three approved inspections:
is correct
rect 1 M1aw reo om application aand s<a n that the above infoordinances an. Pre, inprogress,ress, and final. If roof is applied without first obtaining an
tat. l o.re�ct�,ffinge m comely with a city std'county ordinances and-. P g PP 9
erste lew,1Wttng 10 building construction, and hereby authorize represen" inspection, I agree I will remove all new material for inspection.'
tetive-o1�IMs,uty 1.enur upon the above-mentlonad property for Inspection
Perpo.a(
-110:) apo. [o live, indemnify and keep harmless the City of Cupertino
against liabilities.Judgment,costa and expenses which may In any way accrue �/vAI1 /�
against said City in consequence Of the greeting Of this permit. - //hl_/1 /V ` '-1
SIGNATURE OF APPLICANT ^ /-3
1� I
' DATE
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION - FINAL INSPECTION
[INSPECTIONS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED-FOR INSPECTION
OFFICE COPY
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taupe,
Ilnv, Cnlllv,n6 9. 1
•cicphvnul hour 151,1;V5
btl'Alt IM@lit O� PInFII IIbIG nrlu UFv FtOf MFllf tG bcr, ijdRi4tl, i�tilolt
SUI1JJiCl'' �p SU�INCI,iOI rTtilU11O1in11U1JPI5l'JCI Otul71mc�11171r
1.
wtui
Prior topeen lC l.ssuallce,
YOU nNst agree �o jY �•iJ.C.
st;alxlvct; alxl uvu)uI'.aolw:ers silo's p17 rerooljJxJ•
ll.l-1 Aolou� f, tH����liUx� ul1
verllx ^ sllall Ilol: be app h
z New roof w J ' ruval. O-ulll U3o wLidj {r�� .�'i �jl>� ��pQOlor
jl)Spec t iolI alxl wl:l.L,,,a api - rn'�1
il3speclloll alxl approval shall Jg obbbled ircnn Ul9
Mlllell 1130 reu:ooLllxJ is ccnnplel-ect.
� . Allt:yp�� of: ):ooC rl>aJ:l
be
l)upeoLed prior
illslalled. 2 ails �.
A . :U1 order to receive a Jbial, you IMPS
b 'ccalplet-s u�ep� lr r
Pi:elllspecUID ai�iroval
2, xlipcoyres5 l,lupecl;lolt approval
J , 1 jJ3al J ISPQC�loll approval
a pperable snolco dol;eclor ver�lltloii
b. Spark aj:I:Q- oc llulallalloll ot�oN/ yod H11i
a l.1 ed wlUloui J:lt:sl oblajJt�l>��xj �lLgpeo�oC
r, Il ally root 1, ppto
re3novo ralol fall " el: I r)owl Ula' le�lleeaU>ll)q
will jll,pe y H}'111 71It
wr uriUctislnNU 'lett; AMU poixcY ort tlrtteorltro t>�Id Hzl#, boMkL
mucx
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u�oc>rrrtttvs rlr,ri
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1
Ohl of Ct��ici iiilo
S r.v.ua,sva
10)00 Ione Ayowe Cuppllno,C�9,015-0500
C1 ,,I no,CA 7501 3755
t cicphooc: (4001 1;14505
rAX: Ia0U1 151 0153
COMMUNIty DOW.01'MI'mt
sumo T: SMOICC DUIECrOR CMrIFlcNIC OF CMP—UMC$
I ulxlerstalxl and ccmvj.y wiUt Section 1210a of U,e UnIform Code.
Section 1210a requires wile» repairs to a s imvuudy exceed
rltedlon�glelhIr4 or
a smoke detector will be ingWled,
will ill each sleepilxl room and at a point centraip �tltposeg.�Il
ie
corridor or area givilxl aecesg oWtoroans used
detector for
recplit�.
existing smoke detectors canply,
• T ulxterstand Uie above requiremejIt a1>a cerUry bolt we Now have smoke
detectors installed Ulat doffcomply.
ALUIE5S: I (awe
PErM T MUMBM!
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