R 3882 PERMIT
APPLICATION FOR c .CIN of cuPERTINo INUMBER R" 3882
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK 15 NOT STARTED
WITHIN 150 DAYS OF PERMIT ISSUANCE OR
150 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS I I'/'Yy'l �/' BUILDING USE
l v� , lox O RESIDENTIAL COMMERCIAL OTHER
OWNER'
NAME —�-J � ' � FIREARDOUS ROOF
COVERING
C � �y-y� AREA CLASS
ADDRESSv/- EXISTING ROOF COVERING
PHONE i ZSSZ— NUMBER OF EXISTING COVERINGS
CONTR TO�1 /R'•5�,,,� C
I ✓)
NAME ' 1�`, TO BE REMOVED I TO BE RETAINED
,UV I
t TYPE OF ROOF COVERING
ADDRESS I`f v
CITY 81J�_lQ V EXISTING
PHONE-- ` ('1
��l �J C� n� BUILT-UP ROOF
LICENSE ASPHALT SHINGLE
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I baby ctic, that I Of Ilwmed under provbiom of Chapter 9(comment
cine with Sactio 7001 of Division of tM Bevin n• ProLMlon cod., WOOD SHINGLES
and my Ilunu i full and.Ilett.
Leeena clan L_J OIJI BUILDER DECLA r OTHER (SPECIFY) '\
Den�_ ]TT--I•C�� Contract r \\
hereby win affirm the I am exempt trim the Contractor', Code Law for PROPOSED
the following icon. (Sac. permit, Busing.and Profession,improve,
ve,c Ani city
n. countyE,anv which requires • permit to conaten, site. improv,d.mor such
repair any structure,prior to Its issuance,I nice sed pus Net toe he provisions for wch BUILT-UP ROOF
permit to Ola a signed ens. Low Net he b (Com pursuant to the tion ^^
of the Contractors License Law(Chapter 9 (Commencing or that wiis xempnthere) V
of he
0 of the*for the
and ged ...m tion. or Net oa is n .1 l they. ASPHALT SHINGLES
from and the basisapplicant
for the allege aX.mpts the
Any violation of Section u Iins
7031.5 by any fixh for•permit subjects the appliGnt to a civil penalty P
of not more that ilea hundred dollen($5y em WOOD SHAKES
I, ti owner o1 IM1h property, or he employees with wends d their ale
fompa (See, 04 d0 the work, and the structure is not intended or oaoetl JAN 25 1995--
for uta (See. appl4.y
Business and f property
who The Oomprove•License WOOD SHINGLES
Law dose not such to an owner of hr o gh who build)or improves oven provided
that
and who dose such work himself or through his own employees,provitlaE that
such improvements are not intended or offered for sale. If, however, the OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner Gu r
builder will have the burden of proving that he did not build or improve for
purport of)alai. PROVIDE I.C.B.O. REPORT NO.
I,
as owner o1 the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions
Code: TheContractor's License Low does not apply to an owner of Property pROVIDEMFGR. INSTALLATIONSPECS.
who build) or improves ther.un,and who contracts for such projects with e
contractor(*)licensed pursuant to the Contractor's License Lew.
pn I .m exempt „std.. sap. ,e.aP.c.for this
e. APPLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION p Building
I hereby sifirm that I have s cartilicns of consent to self in ,or•co 1 ✓✓ //�� 6D
bolter.of W3800,Leore Comgga,�Xtion Int encyL a,or,e cert Hyd copy t roof(Sac. �9— �����'SeismicCer
Policy No pony �ry/ �
60)
-Ry CerbRad copy i*hereby furnished. Total
tI If..PY i) N
filed with .city inspection division.
Applicant
CERTIFICATE OF EXEMPTION
ON INSUFROM RANCE WORKERS' N.C.
C, ❑ PERMIT AUTHORIZATION DATE
COMPENSAT(This action need not be completed it the permit is for one hundred dol
jars d, I s ll Ieea.l
I certify that in Ne performance of the work for which this permit is f
awed, 1 shall not employ any person o in my manner to as to become subject o 1 _ . -
to the Worker)'Compmatlon Laws of California. 1mg \Vf]`V
Date Applicant
NOTICE TO APPLICANT: 11, after making this Certificate of Exemption,
you should become subject to the Workers'Compensation provisions of the
Labor Coda,you must forthwith comply with such provisions or this permit All roofs being acted rlortoen roofing material bean
.hall be deemed revoked. P P Y 9 g
I certify that I have had this application and.e1.tn.t the above inform. Installed If a root is Installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinances and inspection,18 agree t0 r move all new materials fOrine eCt On.
ante law* elating to enter
ubuilding construction.ab ve- end banpr authorize represent p W Vt � � I ` ��
state l w this ting to onto upon the abov. . and hereby
property for inspection
rr
purPo..s.
(Wel agree to save, indemnify and keep harmless the City of Cupertino
.gsinn liabilities,Judgments,con*and expenses which may in any wry eettu.
asism)t acid City 1n cons.0uence of the granting of this permit. SIGNATURE OF APPLICANT DATE 1
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL /�-�S`
INSP. DATE INSP. DATE INSP. DATE 9!
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY