R 3994 OMBERRasRMIT
APPLICATION FOR CITY OF CUPERTINO 3994
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN IN DAYS OFPERM T ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �n1 BUILDING USE
LI/) /;/L V/ RESIDENTIAL! COMMERCIAL OTHER
CWIPIER'S
ROOF
NAME 8Q L1 JZ 7r- FIREAR HAZARDOUS COVERING
AREA CLASS
ADDRESS YYl L EXISTING ROOF COVERING
PHONE ,3-yZ NUMBER OF EXISTING COVERINGS I
CONTRA TOR'S
NAME Qkcq TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
CITY&ZIP c EXISTING
♦ PHONE LQS Ta s BUILT-UP ROOF
LICENSE' / ASPHALT SHINGLES
NUMBER49-5 3 So WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I m hereby affirthat I em licensee under provision.of Chapter B(common
cin. with Section 7000) of Division 0 ere the duan...and P,.I..I.n.Code, WOOD SHINGLES
and mY Ilunu I f ILct.
License lob Lic.Number<--31
Data "f-3�_ Contractor OTHER (SPECIFY)
OWNER BUILDER DECLARATION �y
I herm eby Ofirthat I em..amp, from me CPptncl Ys Li ems Ley�.fdr PROPOSED
the following,...... (Son,. ]0]1.8, Business and Prof..,ons' [I•y,4wy city
or county which requires a permit to constru t, elter,� yr v ,aymoluh,or
nisei,any structure,prior to it,issuance,aeroiIr is ant for wch gUl LT-UP ROOF
Permit to file a signed statement mn
at h•Is Ilc• a us he or Ions
of the Contractor's License Law (Chapter 8 (CO nci Setif ]000)
of Division 3 of ter•Bmin...and PIlagrof..sionof7a o s pt there ASPHALT SHINGLES
•
from and the bila for the .pormi expie sip of penalty
]001.6 by any t v.hu for•.omit pie to the ivil isostery V
ofnotmm•tPh fivhuntlratldol S90.I WOOD SHAKES �s<Z C" �Gul/
O I,s.owner o1 the proper _9 h wapas I.their gob i
compensation,will do the work:. d /R not intended or offered
for tele(Sec. 7044, Business alhd P 1 e: The Contractor's License WOOD SHINGLES
Law doma not apply to•g ere I.,P 9 M10 build.or improv..thereon,
. and who don such work•himfll� Phown am ploy..;
impl.y. nl, provided that
much era o6t`int •(mor o red fpr sale. If, however, the OTHER (SPECIFY)
building or irose ninom.—, hin one veer of completion, the owner
builds,Will have-lie burdUvof proving tn.,he did not build or improv for
P.1p.teof.ale.). PROVIDE I.C.B.O. REPORT NO.
0 I, as owner .1 In p property,am exclusively contracting with licensed
contractors to con.Fuct"th. project (Sec. 7044, Business and Plot...ion,
Codas The Contractor's License Law dobhot apply toanown.,ofproperty PROVIDE MFG R. INSTALLATION SPECS.
.no
builds or improve. th.r•un. and who contracts for such projects with .
contractor(.licensed pursuant to the Contractor'.License Law.
reason APPLICATION
am ...MPt under Sec. ,B.&PSC.for this
DATE VALUATION PERMIT FEE
Own., Data
WORKERS'COMPENSATION DECLARATION �v Building
1 hereby offbm that I have•certificate of con.ent to..If inure,.,a car 1 U
tilicen of Worker.'Comp•n.nl Insurance,or•car' ad copy mereof(Sec. Seismic
♦ 0800,Lab ///t��,//� I\
Policy No II 7�I�y OM U _
6 CertHl•d cdPv Ia hereby furnished. �� N( U�rc�lu4 / /O O Total / 0
-� C.rtill copy i.filed with the city inspection divl.i.h. I`t ser D
Applicant
I CERTIFICATE OF EXEMPTION FROM WORKERS' N D PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(Ther )or qn stud not be completed it the permit is for one hunmad doss
Par.
(5100)or ler..) �—
I caI shall
that m the performance of the work for which this Permit i.
to the .reel not employ any a person In any manner w as to become mbleet
C the Workers'Compensetlon Lew.of California.
Dat• AT: If,
NOTICE should
APPLICANT: o hear Worker,'
visa Certificate of EXhmption,
You
.hood. become It fort i the comply
with
Compansnlon prove Worn a the
Labor dee you nun forthwith comply win auto prwi.ipm qr this permit All roofs shall be Inspected prior to an roofing material being
shell b•eeemae revoked. P p Y 1d 1J
Icertify that 1 have rend this application and nae that the above informs. installed. If a roof is Installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinanrn ane InsBCtIOn 18 roe to remove all new materials for ins ection.
nen laws relating to building construction. and hereby authorize tepr..m. P g P
tetivn of this city to anter upon the above-mentioned property for inspection
IWa) all to Save, indemnify and keep harmless the City of Cupertino ( /
agaiut li•bil ity i consequence
ss,cons and expenses which may in mY wry nerve
awinn.aid City in conuquanu of the ynminp of this permit. $ICDA TURE 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
OMBERRasRMIT
APPLICATION FOR CITY OF CUPERTINO 3994
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN IN DAYS OFPERM T ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �n1 BUILDING USE
LI/) /;/L V/ RESIDENTIAL! COMMERCIAL OTHER
CWIPIER'S
ROOF
NAME 8Q L1 JZ 7r- FIREAR HAZARDOUS COVERING
AREA CLASS
ADDRESS YYl L EXISTING ROOF COVERING
PHONE ,3-yZ NUMBER OF EXISTING COVERINGS I
CONTRA TOR'S
NAME Qkcq TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
CITY&ZIP c EXISTING
♦ PHONE LQS Ta s BUILT-UP ROOF
LICENSE' / ASPHALT SHINGLES
NUMBER49-5 3 So WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I m hereby affirthat I em licensee under provision.of Chapter B(common
cin. with Section 7000) of Division 0 ere the duan...and P,.I..I.n.Code, WOOD SHINGLES
and mY Ilunu I f ILct.
License lob Lic.Number<--31
Data "f-3�_ Contractor OTHER (SPECIFY)
OWNER BUILDER DECLARATION �y
I herm eby Ofirthat I em..amp, from me CPptncl Ys Li ems Ley�.fdr PROPOSED
the following,...... (Son,. ]0]1.8, Business and Prof..,ons' [I•y,4wy city
or county which requires a permit to constru t, elter,� yr v ,aymoluh,or
nisei,any structure,prior to it,issuance,aeroiIr is ant for wch gUl LT-UP ROOF
Permit to file a signed statement mn
at h•Is Ilc• a us he or Ions
of the Contractor's License Law (Chapter 8 (CO nci Setif ]000)
of Division 3 of ter•Bmin...and PIlagrof..sionof7a o s pt there ASPHALT SHINGLES
•
from and the bila for the .pormi expie sip of penalty
]001.6 by any t v.hu for•.omit pie to the ivil isostery V
ofnotmm•tPh fivhuntlratldol S90.I WOOD SHAKES �s<Z C" �Gul/
O I,s.owner o1 the proper _9 h wapas I.their gob i
compensation,will do the work:. d /R not intended or offered
for tele(Sec. 7044, Business alhd P 1 e: The Contractor's License WOOD SHINGLES
Law doma not apply to•g ere I.,P 9 M10 build.or improv..thereon,
. and who don such work•himfll� Phown am ploy..;
impl.y. nl, provided that
much era o6t`int •(mor o red fpr sale. If, however, the OTHER (SPECIFY)
building or irose ninom.—, hin one veer of completion, the owner
builds,Will have-lie burdUvof proving tn.,he did not build or improv for
P.1p.teof.ale.). PROVIDE I.C.B.O. REPORT NO.
0 I, as owner .1 In p property,am exclusively contracting with licensed
contractors to con.Fuct"th. project (Sec. 7044, Business and Plot...ion,
Codas The Contractor's License Law dobhot apply toanown.,ofproperty PROVIDE MFG R. INSTALLATION SPECS.
.no
builds or improve. th.r•un. and who contracts for such projects with .
contractor(.licensed pursuant to the Contractor'.License Law.
reason APPLICATION
am ...MPt under Sec. ,B.&PSC.for this
DATE VALUATION PERMIT FEE
Own., Data
WORKERS'COMPENSATION DECLARATION �v Building
1 hereby offbm that I have•certificate of con.ent to..If inure,.,a car 1 U
tilicen of Worker.'Comp•n.nl Insurance,or•car' ad copy mereof(Sec. Seismic
♦ 0800,Lab ///t��,//� I\
Policy No II 7�I�y OM U _
6 CertHl•d cdPv Ia hereby furnished. �� N( U�rc�lu4 / /O O Total / 0
-� C.rtill copy i.filed with the city inspection divl.i.h. I`t ser D
Applicant
I CERTIFICATE OF EXEMPTION FROM WORKERS' N D PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(Ther )or qn stud not be completed it the permit is for one hunmad doss
Par.
(5100)or ler..) �—
I caI shall
that m the performance of the work for which this Permit i.
to the .reel not employ any a person In any manner w as to become mbleet
C the Workers'Compensetlon Lew.of California.
Dat• AT: If,
NOTICE should
APPLICANT: o hear Worker,'
visa Certificate of EXhmption,
You
.hood. become It fort i the comply
with
Compansnlon prove Worn a the
Labor dee you nun forthwith comply win auto prwi.ipm qr this permit All roofs shall be Inspected prior to an roofing material being
shell b•eeemae revoked. P p Y 1d 1J
Icertify that 1 have rend this application and nae that the above informs. installed. If a roof is Installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinanrn ane InsBCtIOn 18 roe to remove all new materials for ins ection.
nen laws relating to building construction. and hereby authorize tepr..m. P g P
tetivn of this city to anter upon the above-mentioned property for inspection
IWa) all to Save, indemnify and keep harmless the City of Cupertino ( /
agaiut li•bil ity i consequence
ss,cons and expenses which may in mY wry nerve
awinn.aid City in conuquanu of the ynminp of this permit. $ICDA TURE 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