R 3809 (2) APPLICATION FOR PERMIT Rea 3809
CITY OF CUPERTINO NUMBER
RAs
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 WITMIT HIN IEXPIRES IF WORK IS NOT STARTED
BO DAYS OF PERMIT ISSUANCE OR
180DAYSFROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING
/', �� ,y7 // � '�`7 BUILDING USE
75015 ^t�w I RESIDENTIAL ' \COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME FIRE COVERING
�
I� ��`- AREA CLASS
I
ADDRESS ` i �` ir^Win., oil EXISTING ROOF COVERING
.II PHONE 2" 'F ( — 10q ,;)_ NUMBER OF EXISTING COVERINGS
CONTRACTOFj;S_ ^ ,.,�f^n I
J: l/-I� ,/I/v
�Y/ rI/ rvly7J�"'f/lYl TO BE REMOVED TO BE RETAINED.�J�
NAME
�y(� / I� �/�� I n 1 TYPE OF ROOF COVERING
CIITY&zips�'/TJX�(//oI �,�III/f1L�C� 1 (��l�ih �+ l.C� EXISTING
PHONE , Ifoq--7,44 J BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER
WOOD SHAKES
LICENSED CONTRACTORSDECLARATION
I hereby affirm roar I am licenseddunder untla provisions of Chapter n IcOmmem '1
cine with Section 70001 of Division 3 of the Bmines.•f d fr t9n�i�Cod., WOOD SHINGLES 1
and my II<•nea bM ria end effect' (9 W Y�
License Ilej. C6 Lice Number
D•a• conaraetor OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am...mpt from the Com ractor'• License Law for PROPOSED
the following reason. (Sec. 7031.8, Business and Profession.Cotlr. AnY chy
or county which requires a Permit to construct,alter, improve.
d•molifn,or
r•p.lr any structure,prior to Its issuance• eI..require*the applicant for such C1/r
oerm it to Its a signed statement that he I.licensed pursuant to the provision. BUILT-UP ROOF
of the Contractor. License Law (Chapter S (commencing with S•clian 1000)
of Division 3 DI the Business mtl P,oalleged
exemption.
tion. or ton he ti n of S mem ASPHALT SHINGLES _
I from and the beds for the al Pani acem...the
Any ant to On of Section
of a.8 by any applicant lir• Permit wbI¢L tna appu<ent[P a civil penalty
of not mm•that five the pro dollen r my em WOOD SHAKES
❑ I,as Owner of Ib property, or he employees with wends at their*ole
for
(Sec. will do she work, and the rt.Co re If not intended '.Loff icentl
for*ale (Sec. 7044, 1...o and f rep.,,Dade: Tata or improve,
License WOOD SHINGLES
Law who
not apply roan owner of property who beim to improves•nate°., r_
end woo d0°*fent walk himselfint or through o M1i.Own employees.Provided reset Yfl"f`/'\'p-/-`/^.`.✓/jv
such I inng of improvement
are not intended or one
vstl lel fele. If, however, me OTHER (SPECIFY)
building or Improvement If .nisi ovinia one year PI completion, m•owner
builder will have the burden of proving ton he tli0 not build or improve for
ppr0 °a..lee). PROVIDE I.C.B.O. REPORT NO.
❑ I, s owner of me property,project ( •cclu044, contraction wi to licensed
contractor. to con tor's me seLw (Sec. ,aP Business nen end f pNperty
code: The Contractor's License and who o acts w m oh proje t,with PROVIDE MFGR. INSTALLATION SPECS.
who
builds or improves thant to and who acto 'scontracts for such Prol¢b with
contract am licensed pursuant to me Contractor's License Lew.
tee❑n I am season[ antler Sec. ,Bea P.C.for this
,..on APPLICATION DATE VALUATION PERMIT F
Data
t WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that I have a certificate of consent to sell-insure,or•car
tificat.of Worken'Comp shoo Inver or cerci I. PPY meraol(Sec. , seismic
3800,Lab.l� 717 {{))O� ��:����/� 7
Policy No. I � bmpeny Vl •tib.+ c
8 D tlf1m e.ebY Iu, SEP 5 199E `� �� Total
Ceti *red wi 'y .pennon vision.
APPlic sot
C TIFICA E OF EXEMPTION FROM WORKERS' I ,J,' ,PERMIT AUTHOR19AILOk
C MPENSATION INSURANCE N.C. F1DATE
(This action need not be c°mpined it the permit it for one hundred dab
Iso Ifa001 or that
i
1 coI ha Snot in the pony person of the work for which this permit if
to,he I mall not employ Compensation
any pawn In env manner fo a to become subject
to tae Workers'Compm.atioic Lawf of California
Det. Applicant
NOTICE APPLICANT: or this of Exemption
YO" should b.oume ."Diver o me Workers'Compensation Provision. m.
Leber Code, you men forthwith comply With such p.ovisionf or his permit
All roofs shall be inspected prior roofing material being
shall be deemed revoked. P P y g
I certify that I have read this application and state that the above Informs. Installed If a roof Is Installed without first obtaining an
Von is ps.rela. I agree to ng owith construction.all airy andher <Oanty orizewca and Inspection,I a ee to remove all new materials for Inspection.
'alta lives hiscity o builtllnp theaboand hereby authorize nprnm
purposes of this city to ante epees Me above mentioned property for Impaction
Purpose*.
IWtl agree 1.s. sew, indemnify costs
and kap es which the In a OI Cupertino 11{•
against liabilities.I consequence
teen and expanses which may In env sues accrue
en•ima said City In consequence of the granting of this permit. SI NATURE 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 CAPY