R 3187 PERMIT 31 .81
APPLICATION FOR CITY OF CUPERTINO NUMBER RSS
REROOF PERMIT INSPECTION DIVISION ,'PERMIT EXPIRATION
(408) 252-4505 EXT. 228 WIPERMIT ED
THIN EXPIRES80 DAYS OF PERM T ISSUANOT NCE
180 OAFROM LAST CALLED INSPECTION,
BUILDING ADDRESS
�'���� BUILDINN G USE
LL RESIDENTIAL COMMERCIAL OTHER—
OWNERS
THER
OWNER'S
1t HAZARDOUS ROOF ••nn
NAME �kl—�C.�r^� �� .n` Imo, FIRE ICO,V r ING
—T n AREA ^� CL S
ADDRESS //� �`^TyieiruY �>`, eo6x�'�iuc� %Fa •IN OF COVERING
- - PHONE � OT) X5— CO NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
}., l All
T - � TO BE REMOVED$LS.._ TO BE RETAINED
NAME t \� lAI.�CC. t I�� ,a'n d �In TYPE OF ROOF COVERING
CIT I Vill -5000 tisil it 155E EXISTING
PHON�(O� 673^ l I •BUILT-UP ROOF X
LICENSE L - ' I r'. ",` ASPHALT SHINGLESX
NUMBER. - F'A I V
. I,.
WOOD SHAKES -
LICENSED CONTRACTORS DECLARATION pe
hereby affirm 7000 I am licensed ander provls nes of d Prole s(comment WOOD,SH INGLE§ :� 1993
clop with.Settler 7000) of Division of tna Business entl Professions Code,
end my Ilcmse Isles f i ca entl effect.
Licama Olgs Q3 •�r Lic,ryumbe�.�r( OTHER (SPECIFY) -
Daxa .3 Con"ruidr _! �'vl[ �a`LI' 6x��''�r111fVU -
OWNER-BUILDER DECLARATION'
I hereby affirm that I am exempt from the Contractor', License Law for PROPOSED
the following reason. (Sac, 7001.5, Business and Professions Code: Any city"
or county which requires a permit to construct,alter, improve, tlemc itb,or it
repair my.structure, prior to its issuance, also require+ the applicant for such BUILT-UP ROOF
Permit to file a sign° em
d+taumthat he is licensed pursuant to the provisions
of Na Contractors License Law (Chapter 9 (commencing with Section 7000)
of Division 0 of the Business and Professions Code)or In.,he is exempt mere- ASPHALT,SHINGLES v
from and the bests for thealleged exemptAny violation of Section
for
7001.5 by any applicant fare permit subjects the
me pplicant toe vel penalty
of not mora that five hundred roll
er90fa1� R WOOD SHAKES
❑ 1,a i owner of the proper y, J�-�S�E4�,A``Tffyynn �apGs�j�f to air tree
compensation, will do the work en mr °'°«°'°tl ' WOOD SHINGLES
for sale (Sec. 7044,
Business entl Pr° uon de: ne Comnctrr',License
Lew does not apply to an owner of property who builds or improves thereon, -
and who does such work himself°r through his own employees,provided that
lurch improvem°ms are not intended qr offered for Sala. 11, however, he OTHER (SPECIFY) -
building-pr improvement it sold within one year of completion, the owner
for
builder will have the burden o1 proving that he did not build o improve
pulpa..fftalri PROVIDE I.C.B.O. REPORT NO.
❑ ".as owner of the property, am exclusively contracting with licensed
contractors to construct ma project (Sec. 7044, Business and Professions
Cade: The Contractor'tLicense Law do.,no,apply toanowner°fpr°party PROVIDEMFGR. INSTALLATIONSPECS.
who builds or impioves.thereun, and who contracts for such projects with a
contrectprltl);carried pursuant to rho Contractor'+License Law.
❑ 1 am exempt under Sec. `,B.&P.O.for this
O Date APPLICATION DATE VALUATION PERMIT FEE
WORKERS'COMPENSATION DECLARATION �•Y
I hereby affirm the, I have a certificate of consent to ,If insure or a car"
tificate of Worker; Compensation Insurance,ora certified copy thereof(Sec.
]800,Laby,�„yy �T t4TE FU N C1 SEISMIC
Policy A i 7 CornpenY yk,..
e
Car
ttriad opy is hlit,furnished. - / ,
Certified copy is filed with the city inspection division.
Applicant \
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT VALIDATION DATE
COMPENSATION INSURANCE
(This taction need not be completed If the permit is for on°hundred'dob "
I...151001 rr len.) a - - �
certifysit that in the panto rmencp of the work tern which this permit Is ^�
ntued, 1 shell O[employ any par, n in an men ib °° sublect -`(
to Na ry pemation Law+pf rpt /!I m w.
Date Applicant
NOTICE TO APPLICANT: II, of te. �s king CeniI to of Exemption,
you should become subject to the N{,5rkarT moan+ n provisions of the
Labor Code, you must forthwith c ply with .aces a viimnt or this permit. All types of roof shall be inspected prior to any roof being installed.To
hell be tlaemed revoked.
- - receive a final I am aware there will be three approved inspections:
is coy that I have read orohis ly with al end note that the above informs"
non i+ correct. I .are. tr comply with all pnv and county omm.ncp+and Pre, inprogress,and final. If root is applied without first obtaining an I
Rata laws relating to building conttructlon, no hereby authorize represent inspection, I agree I will remove all new material for inspection.
[olives of this city 1p enter upon the above-mentioned property for inspection
purpose'
(We) agree to save, indemnify entl keep harmless the City of Cupertino
aga;nst liabilities,Judgments,costs and expenses which may In any way accrue
against Said City In consequence of the granting of this permit.
—�
SI TUR F APP NT DATE
REQUIRED PRE-INSPECTION IN-PROCES INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE NSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO.ROOF SHALL BE PROVIDED FOR,INSPECTION
OFFICE COPY "
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Cujicillno, Colllunda 95015
103001uric nvmmc ,
cupm161O, C-1IIIurnla 95014
Tcicllliunc: 140111 952.4505 `
bVARIMU'll' Or PLANNING AND U@v[LOWWr
SU131JiCl: IlliCt001C2IG p0L]CX lull �l'1'X 01" CVPLI'CI.'IN0 DUILI7IPIG DTFI12L1.N1LtI1` P1111111
110 ISSUANCE 01' P1:111-11T AND DISP1;CIJON PIt11SG.
I. prior to pe9.•ndt issuanec , you must- agree to ccnnply witlt U.D.C.
sta9xlards and nkulufac.L-urers speols on rero0filY4.
ail
2. New zroof' cave➢ i9x�s shall not be applied HiLl�out Sotc9r �A fiiTal
inspGCLion alx] wriL-ten va
appral from UTe building ixi
ills pection alx] app9roval shall be obt"led from till bUilditxJ thspeclor
when the reroofiixg is conpleLed.
3 . 1+71 type of roof . Shall be
inspecLed prior t O ally roof belhg
iiTstalled.
7.
4, In order to receive a final, you nnasL co5plete steps 11 2( aixl
I. prelnspecLion approval
2. Sliprogress ilTspecti.on 01411:0val
3 , I°inal inspection approval
a, operable sn>oke detector NexificatiOP
b. Spar)c a1-resLor 111SLallaUori
r If any roof is applied wiUIOUL fia:sL obtail&t g an •impectioN, YOU Will
re9nave all new material down to the s1TeaUtiixi a9xi a building �jtapeotor
will i.nspecL• all sheaU11ix1 at LhaL time,
W1 umflut1S191ND 'fills" 11WVL IbLICX ON I1tiRCOroc. 11111 WILL O"am, Will, 111E
MLI:CX
14Ck1UCl•)NGRS HIME: I LA
11pDIUiS5: — ••
. zicllooi�Irlc c�oMl,nNx N71ML'':
11PJ?GIC111r1'15 5IGNnIUM
CITX Ol• CUPEMI. 1O
BUIwING ucPn17(1Mar1•