R-3771 (2) PERMIT
'APPLICATION FOR CITY OF CUPERTINO NUMBER R- 3771
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERM TISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
RD 7 I RESIDENTIAL COMMERCIAL OTHER
OWNER'SROOF
(.
NAME (ZAA +-11 FIREARDOUS � COVERING
AREA CLASS
ADDRESS ;ZDC.7A C.(4 er,!;el EXISTING ROOF COVER/'IN
qG
PHONE 1*)3— SSS NUMBER OF EXISTING COVERINGS /�
CONTRACTOR'S
NAME DC0.r^ Ce/e(1+0.V1D TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
ADDRESS CIITY&ZIP -20 I(>, tOeJ /deo O�
EXISTING
PHONE 3CIr- X57 7a BUILT-UP ROOF
NLICENSE UMBER ASPHALT SHINGLES
WOOD SHA
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under Provisions of Chapter 9(comment
ing with Section 7000) of Division 3 of the Business vP.feaalon.coda, WOOD SH I GLES
and my"Can.I I }orce and affect. 6 `l
License Cnss Lic.Number P OTHER (S CIF l
Dan ( �( Contractor ,�p
Oat I am exempt
fUILDER DECLARATION [�pyUl„�'J1jE
1 hereby affirm that I . ev.5, from the DrntrKforY Lode: Lew for PROPOSED
or following reason. (Seices permit, o construct,n and Plter, i pr Coda: Any city
re county which reoulro a Dermis aso alter, improve, asmolisuch
repels any ile a sin,Prior to itsen the,healso rof the applicant for such BUILT-UP OOF
of the to Nle t signal statLicense
Law that he issuance. licensed(compunug v it the ton 7,00.1 00)
of she Contractor',of the Llunes Lew (Cheerers Code)o that withSection there
'
from
Division 3 of the Business all Proged a i Code)or mane is exempt S ction ASPHALT SH
beer m the anis for me alleged exemption.ubjecthe
Any anttoa 01 Section
7031.6 by any tappi hat five
ant fore permit subjects\ns eOpli<ent to e civil penalty
of not more that,of nhe pro erty, (8 y em WOOD SHAKES ���
❑ I, of owner of the Property, or he employees with tenet as[noir free �e
for ale(Set.
will do sna work, and the structure is not intended 's LHaretl
for lila s no )OAA, to now and f property
who
The 1 improve,
thicema WOOD SHINGLES
Lew does not apply to an owner of Property who builds to improves and that
and who Doo wnM1 work. , inhimself or ed o r offered nib own amalle. If, howl ver ma
buil ng or iemenss ere not old wittl o neyfor fele. If, however,owner OTHER (SPECIFY)
building or improvement is mid proving
toa year of completion, p owner
builder will neva the burden of proving[net he did not build or improve for
purpose of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ 1, as owner of the property,am exclusively contracting with licensed
contractors to construct the Project (Sec. 7044, Business and Profes
ssion
Code: The Contractor's License Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who bunds of mprmo thereon, and who contracts for such Project$with a
contractor(t)li tented pursuant to the Contractor's license Law.
❑ I em exempt under Sec. ,B.IYP.C.for his
APPLICATION DATE VALUATION PERM[ EE
owns Data ryryqq p
WORKERS'COMPENSATION DECLARATION P A O D OT BUlldl
hereby affirm that I have a certificate of consent to self insure,or a car. V�
ofi<ete o1
Workers'Compensation Insurance,or a certified copy thereof(Sac. Seismic
3800.Leo.C.1. fI lap IfQ ���� �o6�
Policy No. Company role .8
8 Certified coP,is hereby furbished. Total
oti
Dfiei
a copy I.filed with macity mpecbon aivi.irn 1^' "
Applicant \I F
CERTIFICATE OF EXEMPTION FROM WORKERS' N D ❑ 'PLANY'PLANAUTHORIZATION DATE
COMPENSATION INSURANCE
(This section need not be completed if the permit if for one hundred do$ I
I (51 00)or Hal
I certify that in the performance o1 th k for which In .permit is
naq I shell of is y any Parson in any en so t »subject
to the IN k ` motion Laws of Califo
Date Applicant
NOTICE ld APPLICANT: o e W making this n . <ne of Eons ofithe
you mown become mblKf t0 ma Workers'Compensation provisions OI ma
Labor Coda, you must forthwith comply with Such provisions or this permit ABfOOfS9h811beIn9 ectad Nortoan f ofln materialbein
shell be deerned rsholked. P p Y g g
I certify that I nave read this application and lieu he,the above hforma Installed If a roof Is Installed without first obtaining an
tion is correct. I agree to comply with all city and county ordinances and inspectl0 fee l0fBR10V 811 w materials for Inspection.
nae laws relating to building construction, and hereby authorize represent r\.
PI(W of fnif city to enter upon thedkabove p mentioned Property for Cupertion
no
purpates.
IWt liabilities.
agree save, indemnify antl keep eshiprr�lzrpiwhich sna City of ay accrue
agai mt piCti consequence
ce of and expenses which May In any way accrue
' again+*aeia City m conae9wKe of ma granting of this perms. SIGNATURE OF APPLICANT 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