R 4132 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 413 2
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITH I N 180 DAYS OF PERMIT ISSUANCE OR
180 DAIS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS � BUILDING USE
O a. t ry CT A-V�� RESIDENTIAL COMMERCIAL OTHER
OWNER'S
NAME Ln1Z fl1 yiJ 7—yy% P. r-jw— FREARDOUS COVOERING
AREA CLASS
ADDRESS0fL tfJCrV lk%P-0- EXISTING ROOFCOVEeR�ING
1 PHONE NUMBER OF EXISTING COVERINGS r
CONTRACTOR'S
NAME A/QLQhE+� TO 8E REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
CITOY&ZII{'l�l/. (�Dp1Cf,�LS�?� Mor) e KISMO �c3D EXISTING
PHONE 777- 033 I BUILT-UP ROOF
LICENSE // ASPHALT SHINGLES
NUMBER b 2 WOOD SHAKES
LICENSED CONTRACTORS DECLARATION /
I hnaby affirm that I am licensed no.,provision.o1 Chapter 9 Icomman V/
sing with Section 7000) of Division S of the B.siness and Professions Cade, WOOD SHINGLES
and my license la.11l y101d'Zr a entl effect. �+�Y
Lustiest clap 1, c7�1 LIc.Number L OTHER (SPECIFY)
Date Contractor
OWNER-BUILDER DECLARATION
I hereby affirm that Iem exempt from the Contract.". Lice. Law for PROPOSED
the following reason. ISec. 7031.6, Business and Professions Code: Any city
or county which requires • Permit to construct, alter, Improve, demolleh,or
repair any structure,prior to in issuance,also requires the epoll unt for such BUILT-UP ROOF
permit to file a signed statement that he Is licensed Pursuant to the prevision,
Of the Contractor', License Lew Ilo e (commenting with Section 7000)
of M on'n 3 of me Business and Profror .ions Code)ar that he is exempt there. ASPHALT SHINGLES
from end the bola for t allege exemption. Any violation o1 Section
7071.6 by any applicant f e Per t.ubl.ci.the applicant t0 a civil penalty
of not mora that Ilve nuntl d doll .IS 00).1: WOOD SHAKES
❑ I,as owner of he doer, .or y employees with Wage.U their sole
tgmpmutl.n,will . the work and structure i.not intended or oiloratl
10'tele sec. 7044, usin sae Pr ions Code: The Contractors License WOOD SHINGLES
Lew does not appl 0 a Ow r of ro arty who build.or improve.thereon,
and no do.such rk im If dr o gh his own employees,provided that
corn ng or impr a his este ad Tho aoetl for ala. I1, however. the OTHER (SPECIFY) �
building or imps amens is .Id i Inin one Year.f completion,the owner /�V
builder will have the bustle of p ovinp that he did not build or improve for L
pulp...of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am .reclusively contracting with licensed
contractors to construct the Project (See. 7044, Business and Pro"no"uns
Code: TheContrector'oLicense Law does not apply toonowns,ofproperty PROVIDEMFGR. INSTALLATIONSPECS.
who builds Or impraves thereon,and who Contracts for such projects with a
contractorn)licensed pursuant to the Contractor'$License Law.
reason1 am .tempt antler Set. ,B.&P.C.for this
Owner PP (CATION DATE VALUATION PERMIT FEE
Date
WORKERS'COMPENSATION DECLARATION x a e
hereby affirm that I have a certificate of consent to self insure,or a car L W Bulldin
• [ilinte of Workers'Compensation Insurance,or a certified copy thereof ISec (•�^ Seismic
0800 Lab.C. 1
Policv N.(yf05Q4-9&Pmpeny LJ'f Ae P1t1 L Jon
o��p.rtiNedreyppyy'.hereby f _ spied. �'^ 9 Total
�C tike Ix,i. l2 wixllit s act on division. C
Applicant . �`.f /�7 rr�if L
CERTIFICATE OF EXEMPTION FROM NSAT ON INSURANCE ORKERS N.D. --iRERMI ORIZATION DATE
COMPEIThis section need not be completed it the permit is for one hundred dol 1
lase 151001 Iess.l
ce
I rtify that in the P.11.1nnnce dl the work for which this Permit is
issued, I shall
hat employ any Perron in any manner so e.to become subject
to the Workers'Compensation Laws OI Qlifornis.
Due NT: If,
APPLICANT:
E TO
NOTICo alter making this Certificate of Eons of the
you r Cod become must
forthwith
i the Worker"Compensation provisions
provisions of the
Labor Cods, you moat forthwith comply with such provldom or this permit All roofs shall be Inspected prior roofing material being
ensu b.seams rrvobtl. P P Y g B
1 certify that 1 have read his appbc.lidh and nate that the above informs. installed If a roof IB Installed without first obtaining an
tion is correct. I agree to comply with all City and county ordinances and ins eeti0 I e grto remove all new material for ins ectiOR
eau lewd r.atin, to building construction, and hereby sumo rile represen
,olivesabove-mention"
t Q 4 g P'//��a■4■
tivOf this cloy w enter he d k e p harmless
Phe Ci V Ids Inspection
purposes.
(We) spree to arve, indemnify entl bap Mrmlese the City of Cupertino
again.,liabilities, judgments,corn and..nr nI which may in any Way accrue SIGNATURE OF APPLICANT DATE
agsinot said City in consequence of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP, DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
T INSP. DATE INSP, DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R- 413 2
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITH I N 180 DAYS OF PERMIT ISSUANCE OR
180 DAIS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS � BUILDING USE
O a. t ry CT A-V�� RESIDENTIAL COMMERCIAL OTHER
OWNER'S
NAME Ln1Z fl1 yiJ 7—yy% P. r-jw— FREARDOUS COVOERING
AREA CLASS
ADDRESS0fL tfJCrV lk%P-0- EXISTING ROOFCOVEeR�ING
1 PHONE NUMBER OF EXISTING COVERINGS r
CONTRACTOR'S
NAME A/QLQhE+� TO 8E REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
CITOY&ZII{'l�l/. (�Dp1Cf,�LS�?� Mor) e KISMO �c3D EXISTING
PHONE 777- 033 I BUILT-UP ROOF
LICENSE // ASPHALT SHINGLES
NUMBER b 2 WOOD SHAKES
LICENSED CONTRACTORS DECLARATION /
I hnaby affirm that I am licensed no.,provision.o1 Chapter 9 Icomman V/
sing with Section 7000) of Division S of the B.siness and Professions Cade, WOOD SHINGLES
and my license la.11l y101d'Zr a entl effect. �+�Y
Lustiest clap 1, c7�1 LIc.Number L OTHER (SPECIFY)
Date Contractor
OWNER-BUILDER DECLARATION
I hereby affirm that Iem exempt from the Contract.". Lice. Law for PROPOSED
the following reason. ISec. 7031.6, Business and Professions Code: Any city
or county which requires • Permit to construct, alter, Improve, demolleh,or
repair any structure,prior to in issuance,also requires the epoll unt for such BUILT-UP ROOF
permit to file a signed statement that he Is licensed Pursuant to the prevision,
Of the Contractor', License Lew Ilo e (commenting with Section 7000)
of M on'n 3 of me Business and Profror .ions Code)ar that he is exempt there. ASPHALT SHINGLES
from end the bola for t allege exemption. Any violation o1 Section
7071.6 by any applicant f e Per t.ubl.ci.the applicant t0 a civil penalty
of not mora that Ilve nuntl d doll .IS 00).1: WOOD SHAKES
❑ I,as owner of he doer, .or y employees with Wage.U their sole
tgmpmutl.n,will . the work and structure i.not intended or oiloratl
10'tele sec. 7044, usin sae Pr ions Code: The Contractors License WOOD SHINGLES
Lew does not appl 0 a Ow r of ro arty who build.or improve.thereon,
and no do.such rk im If dr o gh his own employees,provided that
corn ng or impr a his este ad Tho aoetl for ala. I1, however. the OTHER (SPECIFY) �
building or imps amens is .Id i Inin one Year.f completion,the owner /�V
builder will have the bustle of p ovinp that he did not build or improve for L
pulp...of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am .reclusively contracting with licensed
contractors to construct the Project (See. 7044, Business and Pro"no"uns
Code: TheContrector'oLicense Law does not apply toonowns,ofproperty PROVIDEMFGR. INSTALLATIONSPECS.
who builds Or impraves thereon,and who Contracts for such projects with a
contractorn)licensed pursuant to the Contractor'$License Law.
reason1 am .tempt antler Set. ,B.&P.C.for this
Owner PP (CATION DATE VALUATION PERMIT FEE
Date
WORKERS'COMPENSATION DECLARATION x a e
hereby affirm that I have a certificate of consent to self insure,or a car L W Bulldin
• [ilinte of Workers'Compensation Insurance,or a certified copy thereof ISec (•�^ Seismic
0800 Lab.C. 1
Policv N.(yf05Q4-9&Pmpeny LJ'f Ae P1t1 L Jon
o��p.rtiNedreyppyy'.hereby f _ spied. �'^ 9 Total
�C tike Ix,i. l2 wixllit s act on division. C
Applicant . �`.f /�7 rr�if L
CERTIFICATE OF EXEMPTION FROM NSAT ON INSURANCE ORKERS N.D. --iRERMI ORIZATION DATE
COMPEIThis section need not be completed it the permit is for one hundred dol 1
lase 151001 Iess.l
ce
I rtify that in the P.11.1nnnce dl the work for which this Permit is
issued, I shall
hat employ any Perron in any manner so e.to become subject
to the Workers'Compensation Laws OI Qlifornis.
Due NT: If,
APPLICANT:
E TO
NOTICo alter making this Certificate of Eons of the
you r Cod become must
forthwith
i the Worker"Compensation provisions
provisions of the
Labor Cods, you moat forthwith comply with such provldom or this permit All roofs shall be Inspected prior roofing material being
ensu b.seams rrvobtl. P P Y g B
1 certify that 1 have read his appbc.lidh and nate that the above informs. installed If a roof IB Installed without first obtaining an
tion is correct. I agree to comply with all City and county ordinances and ins eeti0 I e grto remove all new material for ins ectiOR
eau lewd r.atin, to building construction, and hereby sumo rile represen
,olivesabove-mention"
t Q 4 g P'//��a■4■
tivOf this cloy w enter he d k e p harmless
Phe Ci V Ids Inspection
purposes.
(We) spree to arve, indemnify entl bap Mrmlese the City of Cupertino
again.,liabilities, judgments,corn and..nr nI which may in any Way accrue SIGNATURE OF APPLICANT DATE
agsinot said City in consequence of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP, DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
T INSP. DATE INSP, DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY