R-3805 (2) PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER Ras 3805
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAYSOF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
1015(9- 10170 FIrwOoA
_ RESIDENTIAL COMMERCIAL OTHER
OWNER'S 1 k�V� ,y, AAA
Go�jo I I lar none rnP/�11 FIRE
COVERING
/{
NAME ,�y� 1
1 AREA rIV CLASS
ADDRESS(Li
35 _fhe,�Iok', la •�� EXISTING ROOF COVERING
PHONE L — J 70
NUMBER OF EXISTING COVERINGS
CONTRACTOR'S n \�
NAMED(- Int rel TO BE REMOVEDTYPE OF ROOF COVERING ED
ADDRESS ))853 Sr741 S �
T Zose,bA 15l)a EXISTING
PHONE
NCO q71-7500 BUILT-UP ROOF
LICENSE17/ I n ASPHALT SHINGLES
NUMBER b b
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
1 nohby Affirm 7000) of Division
under provisions 0a d Chapter s(coons Code,
<Ing with Section )0001 of Division 3 or the Business and Professions Coe., WOOD SHINGLES
and my licensa In force and effsc7. j L� O
ueangs�_ up.Numb. 'TJjLicense
OTHER (SPECIFY.)
Dab m!A Connxcor 1ltt''
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors Lice se Le for PROPOSED
the f"I lowing reason. (Sec. 7031.6, Business and Professions Co Any city
or county which squire{ • Dermis to " hru<t, 'Itar, im Dr tle olisM1,or
spar,any structure,prior to m issuance,."ao requires 7 pplicant ..um BUILT-UP RO
Permit to fila a signed rtetaman[that he is licensed ou ant to the oro 'Siem I
of the Contractors OF.... Law (Chapter 9 (c om cinu with Section 001 �/Ui'tt♦
of Division 3 of the Business end Profes{ions Co or the,h.is'%.high m e ASPHALT$HJlLiLS
\
from and the basis far the 11 111 axe n. AnY violation of Sacti
7031.5 by any applicant for•Darmin su hitt' the applicant t.a civil .net,
of not more that live nvmr.d tlo0ers IS ol.l: WOOD SHAKES
❑ I,a{owner of the prop.,,,, or y emp""yeas Winn wages the sole
mpensation,Will do the work, and t .structure is non intended o o area WOOD SHINGLES
for Sala (Sec. 7044, Business and Profs ions Coda: The ConvacTor'{ - ens'
Lew don of.,,l, to an owner 0f or
erly who builds or imp, on,
and who does such work himself or to ro n his own employee{ D the
such who
are not intended or offeree f ale ty 7 OTHER (SPECIFY) cem
building or improvem.nn is sold wins in a veer le on, n 9
bu"rear will neva tn. burden"t Prov"ng th ha d r u'id �yayto'
Du.poseof See.). ��� PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the property, a xcl s vel,< trwa ith licaned
contractor{ to construct the project (Sec. 44, Business and Profession
Cotla: ThpContractor's License Low does not poly to an owner of prop y PROVIDE MFGR. INSTALLATION SPECS.
who build{ or improve{thereun,and who cont ms for such projects In e
convectors)licensee pursuant to the Contractor Licansa Law.
❑ 1 am exempt under Stec ,0,&P .I.,this
ow`
PPLICATION DATE VALUATION PERMIT FEE
Owner WORKERS'COMPENSATION DECLARATION /�� 3� y/1�� Building
1 MsbY affirm that I have a cartiucna of consent to{0,1 insure.
or a car : JJR I� J 1 OW
tificata of Workers Compensation Insurance or a certiti tl copy thereof"Sec. Seismic
3800,Leb. 6a.IN`�LDo, State Fund
Policy No. vent'
8 Car::;: copy s a. r urmytgtl. Total
Cavin opt'B as th t1v inspection division.
Applicant j 1
CERTIFICATE OF EXEMPT" N FROM WORKERS' N C ❑ PERMIT AUTHORIZATION DATE
COMPENSATION SURANCE
(This{action need not be completed if the vermin is for one nu^a..d deb
bas
($1 DO o.l-%-I
I <eISh that m 700 performance "1 the work for which this permit is v • 1
1.the, rt,.,not emp""y any Parson in my man s"as to become subject
to the Workari Compensation Laws of California.
Data NT. It.
NOTICE Should
APPLICANT: o altar making this Compensation
p of Exemption.
you should become subject vi the Workers h such pstion provision{of me
Shelf cone, ed r moat ro.mwitn comply With .ops provision.or this permit All roofsshall be Inspected prior to any roofing material being
{hell be deemed revoked.
I certify that I have read this application and state that the above Inform@ installed If a roof Is Installed without first Obtaining an
tion is correct. I agree to comply with all city and county ordinances and inspection.I agree to em sae all new materials for inspection
state laws relating to building construction, and hereby authority I.Pasism
jet purpose'.'. this city to enter upon the above mentioned property for impaction 1��/
Pu roes{. ,L, _[Ab Al `l'Y�Y//
(We) all to save, indemnify end keep harmless the City of Cupertino
against liabmtin,ludg,nenn,costs and expenses which may in any was
•cane
against said City in conaa"uanca of the granting of this permit. SIGNATURE OF APPLICANT v DATE
` PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
I\ 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