R 4086ti
OFFICE COPY
PERMIT Ree 4086
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT
EXPIRES IF WORK IS NOT STARTED
(408)252-4505 EXT. 228 WITN IN 160 DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
D s,7S /� c. f /✓I . a yY 2
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
/�
�•F
/
OF
HAZARDOUS ROOERING
NAME J—�J((/ C/A/�
FIRE
AREA CLASS
_lGd
EXISTING ROOF COVERING
�Qy
ADDRESS (5� ^^
NUMBER OF EXISTING COVERINGS /
PHONE W�"i'
CONTRACTOR'S
-L",.,�
TO BE REMOVED � TO BE RETAINED
NAME �eZG� mr+.� �e9O-T�
TYPE Of ROOF COVERING
EXISTING
CIT a iib / Q aa� 8 �//� �
6S
BUILT-UP ROOF X
PHONE/�
LICENSEASPHALT
y Z/O
SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
MAY ± 7 i995
Ihereby affirm that I am licensed undo prwplonF of Chapter f common.
sing with Section ]000) of Division 9 of the Business and Professions Coda,
WOOD SHINGLES
and my license is In I 1 and affect. b, �-� Q
I.I.. Claw 1
CII Y Ur VVI'Ctt I11
Lic. Number
Dan Contractor
OTHER (SPECIFY) Y--- _....
OWNER -BUILDER DECLARATION
I hereby followin affirm that . .xemp, Nom the Convecsio F Code: Lew for
tenon, (ase. business and Professions Coda: Any city
.1
PROPOSED /
ountyiw
which requires a permit an eonrto
Permit, ane, Improve, tlemoli uch
air
re any
repair any structure, prior m In issuance, also re ma applicant for wen
BUILT-UP ROOF
Permit to Iiia sigced statement he is licensed pursuant it the Provisions
sed Pur
of the Contractor's ch
t Law (Chapters (commencing tiatl ]o00)
Division 9 Of me Business end
the Business re
or inn he ti exempt more
a I. ..Mph
ASPHALT SHINGLES
from alleged ..ions tic.. Any violation of Section
Irons antl ins beeps for ms sl loped aempts
]091.6 by any applicant fora permit the
me epplicen, to •civil Penalty
`
of not mora That five hundred dollen I ISBN).):
WOOD SHAKES
I, ti Owner at ma property, or my em: as Meir role
employees with
tense
will do the work, and the structure is not intended or offered
he
for (Soon,
for cele (Sec. 7044, and Code: TherImpovContractor's
WOOD SHINGLES 2\
to f property hereon.
don not apply to en owner of property who builds Improves thereon,
�s4
aLownd who does neih work himself or through his own employees, provided that
to
such
such est not intended or for cele. If, however.
OTHER
OTHER (SPECIFY)
building or improvement i, sold
ng ar improv sold with one veer of err
one year or me owner
builder will have the burden of proving that he did not build or improve for
owing of build
Purpose of select.
I, as owner of the property, contracting with licensed
PROVIDE I.C.B.O. REPORT NO.
connacton to construct the project lana. )044, Business and Prolaxlons
t (ac. 7044, ,
Coda: TheContractor's License Law doe, not apply 1. an owner of property
PROVIDE MFGR. INSTALLATION SPECS.
who build, or improv. mereun, and who contracts far such projects with a
con,rectoris) licensed pursuant to the Contractor's License Lew.
res 0n 1 am exempt under Sec. ,Beed P.C. for this
APPLICATION DATE
VALUATION
PERMIT FEE
Owner Dote
WORKERS' COMP ENSATION DECLARATION
pD
i
Building
I booby orker. [bt I nava i certificate of consent to eelL insure. Vr . •ser.
3800 ab WOrkeri Compensation Incuranca, opaco lied copy tn>reol lSac
9600. Lab. C.1'/yGT'./per
fl'�
��e r
Seismic
Policy N:. Company (.L/s�///
199
-
9 C rifled coot 1a nerebv fu.n d.
Cenil led
Total
copy is filed with the city inspection division.
Applicant
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
N.C.
COMPENSATION NS URANCE D ❑
(This section need not be completed it the permit is for one huntlre f do1-
bn ($ 100) or I.that i
I certify snot in the performance the work for which this permit n
I alke not employ any in any manner m n n become
1
�/
^�,�//— (tel.
Ole- Ql"
1 /�//
(1
touetl, personof
person subject
to the Workeri Compmution Laws of California.
/!�'T'/j� / `
f7
Date AppNT:
NOTICE APPLICANT: If, ager making this nn of Eon, ofithe
You should become subject o the Workers' Compensation phis of me
r Cod i
Lobar Oode, you must forthwith comply With wen proviflon, or this permit
h such provisions
ns .,
ensu be dnmetl revokes.
All roofs shell be Inspected prior roofing materialbein
P P Y 9 9
Icertify that I have read this application and state that the above inform.
Installed. If a roof Is Installed without first obtaining an
non Is correct. I agree to comply with all city and county Ordinances and
anis Is. `.lama to building construction. and hereby eumorne r.,,.an.
ins 110 I agree to remove all new materials Porins action
P 9 P
tail.. of this it, to enter upon ins above mentioned proper,, for on
purposes.
(We) .gree to nye, indemnify and keep harmless ins City of Cup"
P.N no
against liabilities, judgments, costs and expenses which may In any wry accrue/
a
SIG ATURE OF APPLICANT _DA E
IN -PROGRESS:
against sold City in consequence of me granting of this permit.
PRE -INSPECTION:
PLYWOOD:
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