R-3688 PERMIT R- 3688
APPLICATION FOR CITY OF CUPERTINO NUMBER
Res
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(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
26 76 Q S e ve �/� V a RESIDENTIAL COMMERCIAL OTHER
OWNER'S
e /n HAZARDOUS 1 ROOF
NAME �! COVERING
AREA CLASS
ADDRESS Same EXISTING ROOF COVERING
PHONE �' NUMBER OF EXISTING OVERINGS �[
CONTRACjOR'S
/ O.� (J"Q�OS ,QQ TO BE REMOVED TO BE RETAINED
NAME L— l/����•• TYPE OF ROOF COVERING
RESS
CITY III Zip lex 17 2 6,
EXISTING
),ps BUILT-UP ROOF
PHONE—
LICENSE
HONE LICENSE .5(95 �/ ASPHALT SHINGLES X
NUMBER !! !! Y
WOODSHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm 7000 I licenced under i0ns of Chapter (comma.,
tiny wiwithSectionof tion 7000) of Divi.lon 3 of thea B..eusinos and Prof...I. Code, WOOD SHINGLES
and my license In fy 11 force and affect. Q
Lice.Ciess�- %� Lic.Number ✓
Date Contractor OTHER (SPECIFY)
OWNER BUILDER DECLARATIO
I herby affirm met I em ..amps from she Can mor i LicensorW for PROPOSED
the following re (Sec. 7031.5. Bueineee and oteniom Coda: An city
or county whichs ncufires a permit 1.const/ ,alter, improve,demolis or
repair onV structure.prior to in issuance recur s the eppHO. for sun BUILT-UP ROOF
permit 10 fila a signed statement[het licensed pu ant t0 m pipvis10 c
of me Contractors Licanae La pter 8 c wis 70 I
from Diyand 3 or e i afor , ll Proalleged
...m Co of i . �mer ASPHALT SHINGLES
from end ma beck for t a +Ipirmi subjects n. 'clan n f S«sic
]031.6 by any applicant 1 e permit ubjeCjs m lice a civil pen y
01 not more mat Nva nu ndre dollars($5oo).): WOOD SHAKES
❑ I,as owner of
In pro arty, or m u gee est n ole
compensation,will do the wo , end the ° r �y.�9e ended o area
'or sale(Sac. ]oAa, eusin.ss. ProI I ` d.^ryyecdnlr.ct 's Ip.ns• WOOD SHINGLES
Lew does not+pplY to m awns OI prop no buTl9�or improve a son
and who does such work himself r th rose- employ or pr idad that
such improvements a not int° dad or offer calor sale. If, owever, ma OTHER (SPECIFY)
bur:ding or improvement is sold imin one y of compil I n, the owner
but will neve me burden of or ing that he d not buil r improve for
Purpose of sale.). p PROVIDE I.C.B.O. REPORT N0.
❑ I, as owner st ma properly,or
exclusively 4. trotr s an with licensed
<on Vacion to construct the project sec. ]OA., Bus s era Professions C
code: TheConv«tor, F:ns. Law as no, nownerofProperty PROVIDE MFGR. INSTALLATION SPECS. J
who builds or improves thereun, and wh s on Vect or such projects with e
convectors)licensed pursuant to the Oontrr ,an..Law.
m
n l am °`amps under sec. ,e.6 P.c.mr this
raaAPPLICATION DATE VALUATION - PERMIT FEE
Owner Date
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that 1 have a certificate of consent to sell insure,or a car
tifiut.of Workers' Compensation Insurer ancartlfia oDv mereoi sec Baa Seismic
3800,Lab.�CJ. f [f •Tim
Policy No.kj!! ills"sSCompany IIT01'.I.' i'MpBA$2��dn �/s Sr 2QQa
Canilietl copy is hereby lurnis d. `-' Total
Certified copy is filed with me city Inspection mviHon, a� jo ii
AP cant T
CERTIFICATE OF EXEMPTION FROM WORKERS' N C ❑ PERMIT AUTHORIZATION DATE
COMPENSATION I NS URANCE �1tBp� 2)
(This section need not be completed if the permit is for one nundrad d0:. MAR 1 5 1995 ./ I
M1n(5100)or less.) /,
I certify shot in ma performance of the work for which
this permit is [—■I
issued, I shell not employ any parson in any manner so as to become subject Cil . I} i
t0 the Workers'Compensation Law.of California. V J,'
Data Applic.nt
NOTICE TO APPLICANT: It, after making this Certificate of Exemption,
youshould become subject to the Workers'Compensation provisions of the
Labor Coda, you must forthwith comply with such provisions or this permit All roofs shall be inspected prior to any roofing materialbeing
shall be deemed revoked.
I c.rbfy met 1 hey.r.ad thn is applicatioand stets m.t th.above Inform.. Installed If a roof is Installed without first obtaining an
sign is correct. I earee to comply with en city and county ordinances and inspectio lagree to remove all new materials for inspection
state laws relating to building construction, and hereby authorize prawn.
tatives of this city to enter upon the above mentioned property for inspection
purpose.. 3—�
(We) .gree so s+vol, indemnify and keep harmless the City of Cupertino
.gain liabilities,judgments,costs and expenses which may in any way«c me
agi= .id city in consequence of me granting of this permit. SIGNATURE OF APPLICAA � 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 _
IJJEC'I'; III:Il0
IJ0PING POLICY FN 'I'lIE Cl I y 017 CUIIGR'I'INO BUILDING DEPAI
Sl"iMENT
I'It101t'TO ISSUANCI:.017I'ERMII' AND INSI'EC'I'IONT'1IA58.
I. Prior to pcnuil issu:ulcc, you unlsl agree to comply will, U.U.C. standards and manuflclutcls Wee's
on rcroofulg.
f covcriu �s shall uol be applied tvilhoul lirsl obtaining all iusll obhincd fronll, and lllhe building
2. booNckloo 6
book the building inspcctor. A final inspection and approval shall c
inspcctor Ivllcn the Icroormg is cauplcicd.
7. All lypcs of roof shall be ilispccic(l prior to any loot being installed.
III order to Iccclvc ;1 IiIn11, )'Oo Illost eolllplete steps I, 2, and J.
1,) I'Iciuspcclion or Icor olT apploval.
2.) In progress inspccliou approval.
L) Final iuspccl on a I1 Iuoe;d
;I ) Operdlle smoke IICICC(Or Iv ificdion
• b ) Spall( ;11 lcslor IIIst:1111111O11
S. If plywood Is installed, a plywood Illlll Illspectlon Is IC[lubcd.
G. If any roof is aPPlicd without fust obloining ;m inspection, you will be requited to remove all ncry
ON
ulalcrial dolvn to the sbcatbing and :I building inspector Ieill iuspccl all sheathing of that lime.
: UNDEItS'fAIJD '11113 ABOVE POLICY ON ING
41AND WILL COMPLY Wffll "171E
POLICY
IIOMI:OWNCIiS NAME: —
LGA �
Zo �joo Sts�s�s c/lts/�_�tuo
ADDRESS:
s �oofi,�G
ItGIl00PI1JG COMPANY NAML•:
APPLICAN'T'S S1GNA'fURI`:
Cfl'Y OF CUPER'I'INO
UUILUING DEPAIC'I'ML•NT
•
Itcroo fhvi n Ica d