R-3855 PERMIT R« 3855
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)252-4505 EXT. 228 PERMIT
PERMIT 1
80 DAYSNOT STA TED
E OR
'S
180 DAYS 1 1 FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
LI G 1 S RESIDENTIAL COMMERCIAL OTHER
OWNER'S
�J 1 � II HAZARDOUS �y ROOF
Ta
NAME Ob �4,L2-kNfil COVERING
AREA " CLASS
ADDRESS (DCIS (� L-It'l841— VI S+Z% EXISTING ROOF COVERING
PHONE '"I. D G NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
y� h� TO BE REMOVED� TO BE RETAINED
NAME f-acL1. S[L0.StJaLS Iw'v 1�tG1 I VLC, TYPE OF ROO VERING
CIDTDREY&ZIIs ';3O fPked-A-i l AVe- fD
,1 OF
PHONE I ' 4' S
LICENSE IN
NUMBER 'i O'O ES
LICENSED CONTRACTORS DECLARATION I
I hereby affirm that I am licensed under provisions of Chapter S(commons
Cinp with
Section 9000) of Division 3 01 Me Bwinan and Professions cone, LES
and my Iia««a in 1 II for . std affect. '3 a o '
Licm«cljq Z s` uc.Nume.r IS
JDen��-/L Contrxtor
{ OWNER-BUILDER DECLARATION
1 nanby affirm that I am attempt Irgm the Contrector'f License Law br
the following hewn. (Sec. )031.5, Business and Profen ions Code: Any City
01 County which requires a permit to construct, elteq improve, demolifn,or
repair any structure, prior to its issuance,also requires the applicant for such BUILT-UP R00
parmlt to file a signed statement that he is licensed pursuant to ma provision
01 ma Contractor's3fthe License Lew Prowse. s (commencing with Section 7000)
from
m andn 3 pr the Business the
end Professions Con. or , violation he if .1 S coonhere. ASPHALT SHINGLES
from and ma basis for me eReeed attempts th Any attaof Section
.1 31 no, o any applicant lore permit wbiapn the applicant to•civil penalty WOOD SHAKES �x.
01 not mora that five In.Pro erty. o(55op)m i'Ltwl
❑ 1,a compensation owner of the property. or he employee,wim wends es Meir sole
le (See. aI do the work,and ma fnsCode h notintendedottoot offered WOOD SHINGLES
for do(Sec, apply Business and Professions Code: The or improves
thereon,Lew tloaf not apply toe of property his
build'or i es. prov thereon.
sanduch who does such work himself or ed through offered his own amalle. I f, however Inst
wcn improvements are his mnm,a o neya for fare. u, however, err OTHER (SPECIFY)
building or improvement is sola within or
year of of complanion.or m,owner
builder will have the burden of proving that he did not build or improve for
purpose I of.own PROVIDE I.C.B.O. REPORT NO.
❑ I.
n owner of me pe prof, exclusively contracting a what licensed PROVIDE
code. T n to construct ma se La t Isac. t a apply Business end f propi rty
who Tns or improves th roust,and doeswho co tracts for
an owner of with
a PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves matron, end who contracts for such projects wim e
con;nc;am licensed under a to the Contractor's License Lew.
❑ l em •.amps orae. sec. ,B.ay.c.foe anisreason APPLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION Buildin
I hereby affirm that I nave a certificate of consent to self in,ura,or a cAr p I �a
u[a of Workers' Compensation Insurance,or a certified copy thereof(Sec. H �y Z seismic
3800,Lab.C.). �f -L
Policy No V[� g5_V1Zkompany VO I�Ii lnzc"i'1'Tw �t `
13 Certified copy is hereby furnished. �]� Total
Certified copy is file m tpi city inspection division. F 3
Applicant .1[Kcnt �4...s..s.L
95
CERTIFICATE OF EXEM ION FROM WORKERSN.C. 0 f P MIT AUTHORIZATION DATE
COMPENSATION INSURANCEsowljinillu
(This section need not be Completed it the permit is for one hundred dub -
len 151001 or Ion.) _ Lost
ICertify that in me performance of the work for which this permit is
iafursI : tr
hall not,mploy any parson in any manner so as to become subjectAli
to ma Workeri Compmfnion Law.of California
Deu Applicant
NOTICE TO APPLICANT: If, atter making this Certificate of Exemption.
you mould become subject to the Workers' Compensation provisions of the
Labor Code,you must forthwith Comply with such provisions or this permit
.hall be deemed rwoked. All roofs shall be Inspected prior toany roofing materiel being
1 certify that 1 ata«.entl this application and state that the above inform.. Installed. If a roof is installed without first obtaining an
tion I. Cp w,. 1 .g.« n Comply with all city and county ordinances and inspection,I agree to remove all new materials for inspection.
state laws relating to building construction, and hereby authorize represen'
Olivers of this city to enter upon the above mentioned property for inspection .1
purpose,.
(Wal agree to save, indemnify and keep harmless the City of Cup.rtino t2�
'gains;liabilities,judgment;costs and expenses which may In any way Act .
against said City in consequence of the granting of this permit. SIGNATURE OF ANT 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