R 3189 k PERMIT
' APPLICATION FOR CITY OF CUPERTINO NUMBER R— 31891
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
) 252-4505 EXT. 228 PERMIT EXPIRES IF WORK IS NOT STARTED
(408
U 5 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
IBD DAYS FROM LAST CALLED INSPECTION:
BUILDING ADDRESS 7� BUILDING USE
L O 686 OLJ/QI (f 'C/ RESIDENTIAL 1 COMMERCIAL OTHER
OWNER'S - /
NAME S=-Z'J/LQ DN <J IqNSO/t HAZARDOUS ROOF
FIRE V 1/"� COVERING A
AREA n�a� CLASS
ADDRESS 20 6g� 7/L/e e'e--5 EXISTING ROOF COVERING
PHONE Z.SJ — `1S-
1 3 - - NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S _
�/✓OLu3���✓ —� M TO BE REMOVED TO BE RETAINED
NAME { - TYPE OF ROOF COVERING
. C ✓ ,� EXISTING
PHONE -a S BUILT-UP ROOF
LICENSES�Jc—S' ASPHALT SHINGLES
NUMBER J
WOOD SHAKES.
LICENSED CONTRACTORS DECLARATION
1 booby affirm that I of Division
otl 3 .1 t provisions of Chapter s ons(commenCoca �1
cine with Section ]000) re Division J of the Bwineu and Professions Cotle, WOOD.S 1 ■ I 0\I
end my Clan
is In f II farce and affect iy��a—c—� ,
LicenseClm �' Lia Number—il5 J •J
Data -z/,sycontre[eo s o OTHER {BPECOIFuJu itA PU
OWNER-BUILDER DECLARATION
booby reason.
that ., exempt ebm the d Profession.
rofeContractor'siCode:
Lew far PROPOSED
the o county
lowing reason. ISec. .O permit
Business and Plter, i pr Ce, d Any city DATE `/
re sou my which naQuiresPrior a permit t°construct,, alsorPleas improve, tlemoli uch DATE any structure,prior to its issuance,h ei also requires pun the uantapplicantihp for provisions-
BU
LET:-UP ROOF
of the to file t se's Li statement thatheis licensed pursuant the tion 7 00)
of the Contractor's of he License Lew (Chapter , (commencinghot he
is Section In.,.
•
from
Division J of me Besides,the
and alleged
e x old tions)or that he tion of t meren ASPHALT SHINGLES
bom entl the befit for foe apertl exemption. Any violation of Section
.OJo any applicant fivfora permit subjects me applicant to e civil penalty
of Octot more that five hunthe Pr tl dollars r my e.1: WOOD SHAKES
Cl I, ti owner or the property, or he °mploye is with wanes as heir sola
compensation, 0411 do the work, and the structure is not intended 's License
roe sale (Sec. apply
to an
and Profession.Cone. The r impr Contractor's hereon, WOOD SHINGLES
Lew woos not apply o en owner of property who n em to hes, prof deed that
and who r oaf such work no, int nr through roffered hie own employees, howevetl that
"ch ilding r improve Pee doe intone.° or eYa for sal.. H, however, m• OTHER (SPECIFY)
on lour Oe improvement sold within one year of of build
the Owner
builtler will veva the burden of peeving that he tlitl not builtl or Improve for
pofeOs ow'n's PROVIDE I.C.B.O. REPORT NO.
❑ I, of . of the property, t ( ee. 7044,
exclusively contracting a with I este s
Code:
he to construct the project (Seca . spot,
Business1. entl Professions
contractor,
Tds of i rani thicenne and who cot tracts foal ch projener cts
is with
PROVIDE MFGR. INSTALLATION SPECS.
who builds o 'eased pursuant theeed n, entl who contracts fore La prolectf wish °
contractor(s)am licensed under
to the Contractor's License Law.
❑ am exempt anode Se<. ,e.6P.C.for mit
ow.�e
, Date APPLICATION DATE VALUATION PERMIT FEE
WORKERS'COMPENSATION DECLARATION
1 hereby eHind chat I neve a certificate of consent 1.sol6insu re,or car
nfeate of Workers'Compensation Insurance,or a certified copy thereof(Sec.
0000,lab.C.I. S'ra; ✓.Lr •� ] �j SEISMIC
Policy No. Company
® Certified copy is hereby furnished. n _ `
Certified copy le filen w�tbe city Inapeanon nlr isio . A� �-ILL00
Applicant fed ra, — - `•s/
CERTIFICATE OF EXEMPTION FROM WORKERS' PIPRMI' VAL DAT DATE
COMPENSATION INSURANCE 4
I ''11
(Thio section nese not be Completed it the permit is for One hundred wO VVrr
len($100)or les..) w r'1/rryll , �
certify that in the performance of the work for as to twit permit it KL
toissued, shell not employ any person in any manner so as to become subject
to the Wo.kars'Compensation LewP of Celilornie.
Date Applicant
NOTICE TO APPLICANT: o hear making this Compensation
p o1 Exemption,
You should become sables[ to the Workers'Compenanion provieionf of the '
Labor Code, you must forthwith control,with such provision,ar his permit All types of roof Shall be inspected prior to any roof being installed.To
hell be it am ed revoked.
receive a final I am aware there will be three approved inspections:
[army that I have rens his comply
.,In .1 end sued that ma above aces an� Pre,In ro ress,and final, If roof is applied without first obtaining an
tion is correct. 1 agree to c holy wim ell city ane c "nay ordinances n ane P g pp
.taro law. relating . building construction, a boned pr .e property
for rs p ct.o- inspection, I agree I will remove all new material for inspection,
purpose
of this city io anter upon the above-mentioned property for inspection
purPOB L
(We) agree eo sere, indemnify and keep harmless the City of Cupertino
against liabilities, judgments,costs and expenses which may in any way accrue
K� against laid City in consequence of two reaming of this Permit.
eIGNATURE�ICANT DATE
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR ' DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
1
Ohl of Clopierfi►io
P.O.Uo+500
10300 Torre nvcnuCupeiUno,CA 950150500
c
Cuperlino,CA 95014-3255
r` Telephone: (400) 252-4505 -' -
FAX: (400) 82.0753
COMMUNI 1Y DLVEI,OI'MCNT
r
SUBTCCT: SMOICE DFI'IJCIOR =IFICITE OF CCN$PUANCE
I wxlerstand and comply with Section 1210a of the Uniform Building code.
Section 1210a requires when repairs to a single fandly dwelling exceed
$1,000. , a smoke detector will be installed, mounted on the ceiling or
wall in each sleeping room and at a point centrally located in the
corridor or area giving access to rornns used for sleeping purposes. If
existi-ig smoke detectors comply, no new detector shall be required.
I wxierstand the above requirement alai certify that we now have smoke
detectors installed that do comply.
ADDRESS:
PODUT DUMBER: _ 3 �/
1IOMOMIERS SIGTIA'IURE: . C�
DATE: ��-/9 -9 3
RECEIVED,
SnT=(Btnc92/1) MAY 1
CITY OF CUPERTINO