R-3987 PERMIT R« 3987
'
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK Is NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
2\07_jo�_\ _ K�lru RESIDENTIAL COMMERCIAL OTHER
OWNER'S �/ ' `/'�46
NAME Mr ; MM o'*U HAZARDOUS ROOF
K
FIRE �� COVERING
AREA CLASS
ADDRESS Q I Sal Miro rel EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTR TO 'S
oda QYC10. TO BE REMOVED TO BE RETAINED
NAME TYPE OF ROOF COVERING
ADD
IT aZ;I` 350 a , J)n CA 9'llo
EXISTING
PHONE&iE 1 3aa -444 BUILT-UP ROOF -
LICENSE 3 =WOODSHAKE
NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 Icomm-h
ing with Section 70001 of Division 3 of me Business and Prot...loh.coda, WOOD SHINGLES
and my license b in full for..and a$act.
License Claes LC.Number
Den comrKtor OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm that I a exempt Nm othe ComrKmr'. License Law for PROPOSED
ma lpollowinnoon. ($K. 7031.5, Business and Professions Code: Any city
Or county which requires a permit to construct,alter, improve, demolim,Or
impel any structure,prior to Its issuance also re0uires .,.care\IOr.Y<h BU
Lermk to fila a signed statement In.,he is lC....tl rspan[[o a provisions
of ma Contractor's the
License Law (OhaP;ar 9 shun, wim s ,ion 7000)
oI Division 3 m m.BY.in.at.nd Prof.. Code)0,man.is e w m.on ASPHALT SHINGLES
from and the batis for ma a mp,ion. Any violations Section
7031.6 by any applic r a parmil subjects the applicant to a civ penalty
of not mon met a n.ndntl dollen 155001.1: OO ES
❑ I,es Ow r of the propany, or my em yen with w g .t or,mle
fopm.istion. ill do me work, antl me s[ru is not to tied Or Ifered
r.ale Isec. T 4, Blains. and Prof. o Th.�D r'.L an.. WOOD SHINGLES
Lew do not ap Iv ro en owns of oro e\ Dund.d �p pr e. "on
and Who no
w ork himself or v, u own em 1dy61g ided Ih at
much Improyemen ere not intended r .,ad I sly lr'; rwave,. the OTHER (SPECIFY)
building or improv man, is sold wit I tee ve of< plat. me owner.
builder Will have[b burden of or that M1,ti d pot uil or improve for
pulps,..of sale... '4/ PROVIDE I.C.B.O. REPORT NO.
❑ I, e. owns, of a p , o yy��uue14a1Co.,r ming with liun.ed
contncton to connru tE r lett ( 044, Bu ' en and Profess,.ons
Code: The Contractor's woos. Iapply nownarotProperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves ed wh tract such projects with a
contractors]licensed pun anti to Contractor. ansa Law.
❑ I am exempt Ynde Sac. ,B.bP.C.fol mi.
APPLICATION DATE VALUATION PERMIT FEE..
Owner Dna
WORKE RS'C MPENSAT10 ECLARATIOIN p� Buildin�
I nano. affirm met 1 na a C.rtifica of consent to.sit insure,or a or N
3800,a of Workari Compare. fare Imur ce,or ancartiifad copy thereof(Sec. F'1 D Seismic
Policy Lab.CO.
Policy No. Compo /�D .e
I] Certified copy is hereby furnished. I'I(� 1 4 19 S •� / Total
Certified copy is filed with the city inspection division. /VYW]/J
Applicant cu
CERTIFICATE E EXEMPTION FROM WORKERS' N.C. f Ut- 1 PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
IIsection not be completed it me Permit is for one hundred dol f�ryU V 1
Ian(S121O00)or lain.)
I certify [not ,.n ma performance of any
work for canto co permit is
issued,
mall not employCompensation
any Lenon in any manner so as to become.objet,
to the Workers'Compm.etion Laws of California.
Date Applicem
NOTICE TO APPLICANT: If, of tar making this Certificate of Eaampbon,
you should become subject to the Workers' Compensation provisions of the
Labor code, you must forthwith comply with such provisions or this permit
hall be domed revoked. All roofs shall be inspected prior toany roofing materialbeing
s
I certify the' I have read this application and state that the above Informs Installed. If a roof is installed without first obtaining an
tion 1. context. I .gree to Comply with all city and county ordinances and inspection,.agree for move all emu meteri�ls for Inspection.
slate laws relating to building construction, and hereby author,.xe repra.m
tetivn of this city to anter upon the above mentioned property for inspection
,.,Poses. .1(/ a
IW.) egrse to save, indemnify end keep harmless Ma City of Cupertino 4l
again.[liabilities.judgment.,costs and expenses Which may in a way Kcrue
against said City in consequence of the granting of this permit. SIG r
URE OF APPLIC T 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