R 3585•
00
OFFICE COPY
PERMIT Ree 3585
Ree
APPLICATION FOR CIN OF CUPERTINO NUMBER
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITH I N ISO DAYS OF PERMIT ISSUANCE OR
ISO DAIS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
20261 Reinell Place
RESIDENTIAL x COMMERCIAL OTHER
OWNER'S
NAME.. Ross & Marie Oulnn
HAZROOF
FIREARDOUS COVERING"
AREA CLASS ClaSS fi B
EXISTING ROOF COVERING
ADDRESS _ 20261 Rpi npl 1 Place- Cnnert i nn Q5014
PHONE _ _5717
NUMBER OF EXISTING COVERINGS 1
CONTRACTOR'S
TO BE REMOVED 1 TO BE RETAINED O
NAME Security Roofing, Inc.
TYPE OF ROOF COVERING
ADD
P. 0. Box 2450, Menlo Park, Ca. 94026
EXISTING
408- 947-8811
BUILT-UP ROOF
PHONE
SHINGLES
NLICENSE
UMBER 5047
,,,_ASPHALT
00 SHAKES X
LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under Provisions of Chapter 9 Icommm
clop with Section 7000) of Divililon 3 of the Budnus and Pl.faesions Coda,
0D SHINGLES
and my Ilcanse I n 1 forty antl efface
Licans rs — Lic.Number Tom—
Dau Contractor µkyya�,ng , 1
C . 0 SPECIFY)
OWNER -BUILDER DECLARATION
Pr�
I hereby affirm that 1 am exempt from the Contractor'. License Law fol
the fallowing reason. (Sec. 7031.6, Butlin. antl Professions Coda: Any city
or county Which .quires improve,
ry
PROPOSED 17` ( 19A�a
9
• Permit to comtrucq alter, d.moiish,or
,.PN, any structure. Pilo, to Its iew..... elm requires the aPPllun[ far such
BUILT-UP ROOF
Permit to file a signed statement that he Is licensed pursuant to the provitl ons
U, Ll i''li
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Profession, Code) or that he b exempt there
from and the basis lar the alleged exemption, Any violation of Section
ASPHALT SHINGLES
7031.9 by any applicant for a permit sublecte the applicant to a civil penalty
of not more that five hu nand dollars 196001')'
WOOD SHAKES X CTV rl� ❑eau
O I, .owner of the Property. or mY amPloysa With wages as half sola
compensation, will do the Work, and the structure is no, intended or offered
for ale (Sec. 7044, Business and Profession$ Cade: The Contract.,'. License
WOOD SHINGLES
Law do. not apply to an own., .1 Property who build. or improves thereon,
and who does such work himself or through hi, own employees. Provided that
such improvements see not intended or cleared for sale. If, however, the
OTHER (SPECIFY) 30#felt
building or improvement i$ sold within one year of completion, the owne,.
builder will have the burden of proving that he did not build or improve for
purpose of sale.).
c] 1, as owner of the Property, am e.cluslv.ly contracting with licensed
PROVIDE I.C.B.O. REPORT NO.
contractors to construct the project (Sec. 7044, eu$ines, and Pr.faesiom
Code ThaContractor's License Law do..not apply toanowner ofproperty
PROVIDEMFGR.INSTALLATIONSPECS.
who bunds or improves th. a.n, and who contracts for such Pmlacls with a
convaclol(O licensed Pursuant to the Contractor's License Lew.
On I am exempt under Sec. ,Bola P.C. for this
APPLICATION DATE
VALUATION
PERMIT FEE
rex
Owner Date
WORKERS'COMPENSATIONDECLARATION10000
I hereby affirm that I have a certificate .f consent to..If.leisure, 0,. car
Building 147.00
titicate ere Workers' Compensation Insurance, or a certified copy thereof ISac
390Q Nola.
9/ 17/96
'
SelsmiC 1.00
Policy No. — ,9fany /StatP Wnrkman GO p.I
s. Fund
Certified copy is hereby furnished.
Total 14R-00
Certified copy is filed withhtthe citcity inspection division.
A licant
CERTIFICATE OFSATION EXEMPTIONWORKERS' N.C. ❑
COMPE(This
PERMIT AUTHORIZATION
DATE
ROM
action .) of be completed if the permit is for one huntlntl doh
Ian({100) tiIns.)
P� fey /l�
/VII/I/
I certify that in the Parfomri of the work for Which this permit is
U
issued. 1 shall not employ any parson In any manner so as to become subject
I/
to the Wiri Compensation Law, of California.
VR-
Dal. Applicant
NOTTCE TO APPLICANT: If, after making this Certificate of Exemption,
you should became subject t. the Workers' Compensation provisions of the
Lobar Coda, you must forthwith comply with such provision, or his permit
Lebo be o emed .mused.
All roofs shell be Inspected prior to an roofing materiaibein
P P Y g g
I certify that I have .ad this application and ,at. that the above Informs.
Instal l$ if fl ro0 s Installed Without first obtaining an
tion Is correct. I agree to comply with all city and county Ordinances and ��
note laws relating to building construction, and hereby authorize rapresen-
"(�n��p��rt�(� I n 8 re t0 8 OVe BII flterlalS toff 9 BCtiOR
��� g P
'
tniva of this city to onto, upon the above mentioned property for Inspection
Purposes.
(Wal agree to save, indemnity and keep harmlan the City of Cupertino
1
against liabilities, judW.nls, costs and expenses Which may In any way ai
SIGNATURE OF PPLICANT AT
again said City I. om,mu.n.. of me granting of this permit.
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