R-3958 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Rok 3958
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
10 E/ v Dr 9e nom' RESIDENTIAL COMMERCIAL OTHER
OWNER'S is
NAME v V-6�iy e- y �'^ A ROOF
FIREHAZARDOUS ,� /,^ COVERING
CLASS ii
ADDRESS ^joS6��( Ora! c "'1 II • AREA EXISTING ROOF COVERING
PHONE aS / — �� / ( NUMBER OF EXISTING COVERINGS I
CONTRAC OR'S (' //,, /'
NAME -e-" `••� ie1e,I �zkop 1-V �l? - TO BE REMOVED-Y&!; TO BE RETAINED
TYPE OF ROOF COVERING
CIOTDY&ZIP `?Ora 0-44 1/�Id �'[ S3 251
� EXISTING
t q PHONE o 6�_�s /.-T 0 BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
, NUMBER 516 7b WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em If...."under provisions of Chapter 9(Com m
cine with Section 7000) of Division 3 of the Business and Professions oa� WOOD SHINGLES
and my license is In II fone_and affect.
Licema Cle u Lia Numberb
Dan 310E-c. Contractor J OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I nxabr affirm mat I . exempt nom the Contractor s License Lew mr POSED
the(plant. reason. (S«. 7031.6, Business and Professions Code: Any city
County which requires a permit t0 Construct, alar,improve, demolish,ol
or
any structure.prior to its issuance,alto requires the applicant for such BUILT-UP ROOF
permit m
to fila a slurred statement that he is licensed psoant to the provisions
of the Contractors License Law (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Profxsiom Conal or that he is...Or,,nue ASPHALT SHINGLES
from and the bests lar the alleged exemption. Any violation Of Section
7031.6 by any applicant for a permit subject, Ina applicant to a civil penalty
of not mere that five hundred dollars($600).1: WOOD SHAKES
❑ I,as owner of the property, or my employees with wages as their tale
compensation,will do Ina Work, and the structure is not intended or offered WOOD SHINGLES
for salBusiness
. )Deet Business and Professions toes: fine Contractor's License
Lew doer not apply to an owner of property who builds or improves thereon,
and who doer such work himself or through his own employees,provided that
such improvement. ere no, inl.nd.d ser offered for San. If, however, the OTHER (SPECIFY) +'t�✓
building or improvement i sola within one year of completion, the owner
builtlof will have the burden of proving that he aid not build or improve far
purpose of s owns PROVIDE I.C.B.O. REPORT NO.
❑ I, of the property, a utlusi44, cosiness a with licensed ssion%
Code:
odecontra tor.The to trrrstrum the project (Sec. ,app Business and Pr Properly
cod.: Tha Contractor's License Lew apes no,apply fo.such
of Properly
With PROVIDE MFGR. INSTALLATION SPECS.
wM10 bunds a eased pursue ,
thereon, and who actorecn for such orpjacn with e
contractor
ontract am licensed under
S n the Contractor's License Law.
reaprr em exempt crena. sec. ,e.aP.c.for this APPLICATION DATE VALUATION PERMIT FEE
Owner Date—
WORKERS
ate p�
WORKERS'COMPENSATION DECLARATION P A j Building
I honby affirm ,hat I have a car,ificen of consent to telt insure,o �V c5
[ificen of Workers'Compensation Insurance,fiance,or a cartiliatl cops thereof(Sac. n a�.T� Seismic
3800,Lab.C.). /� L✓� lyvL
Polic]y No. Company �e
I] Certified copy is hereby furnished. (,� �/� xv� Total
Certified COPY is filed with the city inspection division. VV
Applicant if),
CERTIFICATE OF EXEMPTION FROM WORKERS' VURERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE N-c-�
Y (This section nxtl not be complelatl if the permit is for one hundred dal tv
tan($100)Or Iess.) 1
I canily the, in the performance Of Ina Work for Which his permit i
issued, 1 shall o,employ any per,Orr ��yyra�f�y Mner TO b ,)ms tubi«t
nthaW rkx C msetion Lem ol�oaPlprnia.
OTIC TO APPLICANT: If, after meld g th arts o1 Exemption,
rhal
ou should D«one aubl«f to aha Workari Compansetion provision of aha
ebo.toe..voa mase farthwifh comets wifn such prayi,iarr.ar,ni.permit All roofs shall be Inspected prior to any roofing materialbeing
b.tla.m.a rxokad.
I certify the I have food this application and state that the above inform& Installed If a roof Is install d without first obtaining an
flan is [one t. I .arae to comply with all city and county ordinances and Inspectio 1 agree tore ov II new materials for Inspection.
Lite lam feting to building construction, and hereby authorise npranm
tetives of this city Io enter OPon the above mentioned property for inspection
Purposes. //ee •�p�0
IW.) agrto sew, keep o
, indemnify and aD harmless the City of Cupertin (� (,'v
against liabilities,judgments,costs and expenses which may in any Way accrue
against said City in consequence of the granting of mit permit. ATURE OF APOLICANT 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