R-3586 PERMIT R_ 3586
APPLICATION FOR CITY OF CUPERTINO NUMBER
Ree
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
10404 Vista Dr. Cupertino, Ca. RESIDENTIAL_ COMMERCIAL OTHER
OWNER'S
Steve Chin HAZARDOUS1 ROOF
NAME FIRE COVERING
AREA CLASS
ADDRESS 2315 Trenton Drive, San Bruno, Ca. EXISTING ROOF COVERING
PHONE (415) 871-7108 NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
Security Roofing Inc. TO BE REMOVED l TO BE RETAINED 1
NAME TYPE OF ROOF COVERING
ADDRESS P 0 Box 2450, Menlo Park, Ca. 94026
CITY&ZIP EXISTING
PHONE (415)591-7663 BUILT-UP ROOF
LICENSE 306844 C-39 CITY LIC 115047 ASPHALT SHINGLES
NUMBER WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I em licensed under provisions of Chapter g(common WOOD SHINGLES
cine with Section 70001 of Division 3 of the Business and Prof...om Code,
and my license q�u fora and effect. 306844 j
LI"""4D�9S' cor;":p„SE�NG IN . OTHER (SPECIFY)
Lau
OWNER-BUILDER DECLARATION
I hereby affirm th.t I am exempt from the Contractor's License Law for PROPOSED
the following reason. (Sec. 7031.8, Business and Professions Code: Any city
or county which requires a permit to construct,alter, improv., dam.lish,or
repair any structure,Prior to its issuance,also requires the applicant for such BUILT-UP ROOF
permit to fila a signed ens. Lostatement that he is licensed pursuant to the provisions
of Ma Contractor's3ot License law (Chapter Professions (commencing wi is xempt 7000)
fr Division 3 of the Bfor th and ged ...trCotlal or that he is exempt th.re ASPHALT SHINGLES
from end she anis for the alleged exemption. Any aviolationtto eat Section
'031no ci any applicant fora permit subjects TM1a applicant aq e civil penalty
of not mo.e mea Rva nendree eonan(f3oa.1: WOOD SHAKES
❑ 1,as
owner of the property, or my empl puma wish wages as mea sale
compensation,will do the work, and the structure Is not intended or offered
for sale (Sec. 7044, Business and Profession$Code: The Connector's License WOOD SHINGLES
Lew dose not apply to an owner of property who builds or improves Thereon,
and who does such work himself or through his own employees,provided that
such improvements are not intended p offered for sale. If, however, me OTHER (SPECIFY) 1111 pl��tt�3011 felt/Elk Pres
bo ilding or improvement is fold within or
year of completion, me ownera ique 11 L yr Shing es
builder will have the burden of proving that he did not build or improvefor
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property, am exclusively connecting with licensed
contactors t. construct the project (Sec. 7044, Business and Professions
Code: TheContractor's License Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thereun, and who contracts for such projects with e
con,actorlaI licensed pursuant to the Contractor's License Lew.
❑ I am exempt under Sac. ,B.bP.C.for anis APPLICATION DATE VALUATION PERMIT FEE
Owner Date
WORKERS'COMPENSATION DECLARATION July 30, 1997 11,000 Building 159.31
1 hereby Hfirm that I have a certificate of cons ant to self insure,or a car Inch
silicate of Work.,. Compensation Infur ance,o a certified copy thereof(Sec. �1 A ' $el3mlc
3800,Lab.C.). P M
Policy No. 265-98ompanv State Fund
_ .sEp]��Certified copy If thereby furnished. Total
)B(Certilied copy is filed with me city inspection division.
Applicant AUG. 11
CERTIFICATE OF EXEMPTION FROM WORKERS' P E RIKIRRUTHORIZATION DATE
COMPENSATION INSURANCE N•C. El
(Thi.faction need not be completed if the permit Is for one hundred dol. Ur WI th I INO
I...If10o1 or les..( �IIs
l certify that in the performance of the work for which this permit is
inuad, I shell not employ any parson In any manner.o as m become subject
to me Workers'Compensation Laws of California.
Cl
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you
Mould 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 rjQrg material being
shall be deemed revoked.
I certify mat I have reed this appliuticin and stet.the,the above inform. Insta fa roof IS installed without first obtaining an
tion i. correct. I .lire. To comply with au city and county ordinances and inspecti n, agree o ova all new met rialsforinspection
.tate laws relating to building construction, and hereby authorize reprafam
tatives of this city to anter upon the sbo isYmsntioned property for inspection `
purPoses. \
we) agree to save, indemnify and keep harmless the City of Cupertino
again,s liabilities,judgments,costs and expon",which may in any way accrue
against said City in consequence of the granting of this permit. $IG ATURE OF APPLIC DA E
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 __ _