R-3444 PERMIT R_ 3444
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMWITHIIT EXPIRES IF N IN DAYS OF PERM RK IS T NOT
OR
190 DAYS FROM LAST CALLED INSPECTION.
1 BUILDING ADDRESS BUILDING USE
1 d
RESIDENTIAL COMMERCIAL OTHER
wNER'S
.�
HAZARDOUS ROOF
NAME FIRE COVERING
AREA CLASS
ADDRESS �Q `t C ' I n I EXISTING ROOF COVERING
PHONE /� NUMBER OF EXISTING COVERINGS
1� l7 v� (cs I
CONTRACT 'S TO BE REMOVED
NAME
r/Y V__Q liD I �' TYPE OF ROOF COVERINGED
CITY I�`? SD. '��� W/ �3�I EXISTING
PHONE �T GBUILT-UP ROOF
LICENSE /j� ` O ASPHALT SHINGLES
D
NUMBER e f WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I n.r.br 01irm that I am licensee under provi.lon.of Chapter 9 Icommem WOOD SHINGLES
alms, with Section 7000) of Divi.lon 3 of ins Business and Prof assns loCode,
and mV C me,Is in to Mort gd }tact. ^
License Lic.Number OTHER (SPECIFY(
Dau ^ Connx.or��1 1A
O NER-BUILDER OECLARA ION y
1 hereby affirm that . exempt from the Connection License Lew for PROPOSED 10
m•following r«son. (Sac. 7 exem from
dna attract ons Coen: Any city - �j
or county which require. a permit to construct,alter, Improve, eemolish,or
repair an,.p..t.nv.prior.o I.Issu.nc.,ono..gl.w.a.n.applicant for such BUILT-UP ROOF
Permit to file a sianed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 70001
of Division 3 of the eu.ineat and Prof«.ions Codol a,mat he is exempt hers ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section e
1176 7031.8 by any t five
team re •dollars
subjects the applicant to a civil penalty '
of not more that fwd nhedr,. aty, r my em WOOD SHAKES
❑ I,no owner of tat•grope,a or he employees with wages as mein sole
compensation,
i . (S . will dE tat•work,dna the on Code is not ontra t 's License WOOD SH INGLES
for.ala (Sea 7044, talon
andn., Prof«tions who The Connectors License
Law when rpt.poly tL an owner of through
is o n em to improves e , rov menton,
and who rdoesimprovements
work hlm_II or through hie own r sole, If provided that I r. 4/ / ff r/r�
such ng or improv are not intended wit. or one
year
for ilia, t1, however o, me /OTHER.ISPECIFY) « l�/r`Q
building or improvement is .old within one Year Li completion, me owner ( /
builder will Few ma bureau of proving that he dltl not build or improv for
purr,...of%el.,l. PROVIDE I.C.B.O. REPORT NO.
❑ I. as owner of the property,am exclusively contracting with licensee
contractor'
to construct the project (Sec. 7044, Business and Profession%
Coda: The Contractor's License Law does not apply to an owner of property PROVIDE MFG R. INSTALLATION SPECS.
wh a
builds or improves thereun, and who conte""for Such projectl with e
contractor(s)licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec. ,8.&P.C.10,this
PPLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION Pl A ' ® __/vy ,x s.C'S Building 100,
I hereby affirm that nava i tanniciran of consent to self inem•, o a car [" \!Jn//, }[%
ue of Workers' Compensation Insurance ora certified cr�Y thereof(Sea Seismic
3800,Lab. j • i t .g q��p
Policy NO.�e�ompeny (lT 1 I LI.
Cara/ie co by fur d. APR Total
8 Cerdtietl .til , utY P non division.
Applicant cI de w -Aq�—NI
CERTIFICATE OF E E fiON FROM WORKERS' 1' ' THORIZATION DATE
COMPENSATION INSURANCE N.C. D
an: section need not be completed if the permit is for one hundred do4
Ian 191001 ornoel
m
I certify that in • performance of the work for which this permit is 1
issued. I .roll not employ any Parson in any manner.o as to bacome.pbjact t
to the Work.,.'Compensation Lms o1 California.
Data Applicant
NOTICE should
APPLICANT: o dinr making this Compensation
p of Exemption,
you ar Cole boome subject i h c mply with
Compensation provisions of the
.hall Code. ird must forthwith comply wins auto provisions of this permit All roofs shall be inspected prior toany rooting material being
.hall be a«mea rhave.
I have I certify that nee this application dna Tete that the above informaInstalled if a roof IS installed without first Obtaining an
tion is correct. 1 ogee to comply with ell city and county ordinances and inspection,I agree to remove all new materials for Inspection.
.,at• laws relating to building construction, end hereby authorize represem
tNvn o, this city to anuli Coen m.above mentioned property for inspection
Pur(We) pat ave, V ,.so
* \�
:n I • to • indemnify cos era keno es which
the City of Cupertino
agel«.ti id Cite., consequence
costs and expense.wt is may in any war accrue
aym.t.aid City in aonseapenae of The granting m[tri.Permit. IGNATURE 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 .-