R-3647 (2) PERMIT R_ 364
7
APPLICATION FOR CIN OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)252-4505 EXT. 228 WIPERMIT EXPIRES IF ED
THIN IN DAYS OF PERM RK IS T ISSUAN CNOT E
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZ
f^w ' 3 fir ' �1^v"1 /'N� AROOU
ROOF
NAME FIRE
$ �., COVVERING
AREA CLASS
0� m EXISTING ROOF COVERING
ADDRESS {� (� q/)�y/� ,
PHONE -' Qhs b NUMBER OF EXISTING COVERINGS
CONTRAC R'S1 II
NAME �1' iiiB 1f1 TO BE REMovETYP OF ROOF COVERINGADDRE
D
CITY&ZIP D16 r 0li� OAl °(� EXISTING
PHONE��S) rLJ - �1 BUILT-UP ROOF
LICENSE /., �f ASPHALT SHINGLES
NUMBER 111 v WOOD SHAKES
eel ni,
LICENSED CONTRACTORS DECLARATION T Iip
I hereby •flirm that 1 em licensed under provisions of Chapter 9(comma m 1 I I g
ing with Section 7000) of Division 3 of the Business and Professions Coda, WOOD SHINGLES
and my license is In full force end affect.
License Cie. Lic.Number
Data Contractor OTHER (SPECIFY)
��g pp
A
OWNER-BUILDER DECLARATION If" I D
I heseby affirm that I am exempt from the Contractor's License Lew for PROPOSED
the following reason. (Sec. 7031.5, Business and Profession Code: Any city
.1 county Which .squires a permit to construct,alter, improve, demoli•h,pr ��/y�R 2 5 1997F [/y1
repair any structure, prior t0 in inuanca also requires the applicant for such BUILT-UP R VAF
permit to lila a signed steNmam the,he is licensed pursuant to the provisions
ofane Contractors License Lew (Chapter 9 (commencing with Section 7000)
of Division 3 of the Business and Projections Code)or that he is exempt mere ASPHALT SHIP dLESUh'Lh I INf 1
• from and ma basis for ma alleged exemption. Any violation of Section
7031.5 by any applicant for a permit subjects me applicant t0 a civil penalty
of not more that five hundred dollars( 50OH: WOOD SHAKES
❑ 1,as owner of the property, or my employees with wages as their sole
compensation,Will do the work, and the structure is not intended or offered
for Nle (Sac. 7044, Business and Professions Code: The Connector's License WOOD SHINGLES 14
Lew dose not apply to an owner of through
who busied. improves thereon,
and who dose such work himself or inro art his own ills or imp provides that
such improvements are not intended or offered for sale, It, however, the OTHER (SPECIFY) c
building or improyement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
Purposaofcsle.l. PROVIDE I.C.B.O. REPORT NO.
D 1, as owner of In. property, em axclufively contracting with licensed
connectors to construct the project (Sac. 7044, Business and Professions
Coda: TheContracto:s License Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
.no builds or improves marwn, and who Contract{IOr such projects with e
connecmrl8Iicanse0 pursuant to the Contractor's License Lew.
0 1 am exempt under Sec. ,B.&P.C.for this
reason APPLICATION DATE VALUATION PERMIT FEE
Owner Data
WORKERS'COMPENSATION DECLARATION 4o Building
I hereby affirm that I neve a certificate of consent to..If naure,o
tificete of Workers Compamnicn Insurance,or a certified copy thereof(Sec. /j,�, $@IsmIC
3800.Lab.C.). L
Policy No: Company I
BCertified top,is hereby furnished. I ` i Total
-Certified Copy is filed with the city inspection division,
Applicant' -% " . ,, I- � — _i?
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C. ERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(Trait )cu Ia nNtl not be completed if ma permit it jOr on.hundred 001
lar{($1UDf cuIan) ..
I certify, thea-in the li fay erson of the work for .1which this permit
is
issued, L{Ihall.not emplOY�a(ty, prison in any mePnar 10 a{t0 become subject
to the Wgrkeri Compensation Laws of California.
Date -;Applicant^
NOTICE .TO APPLICANT: .If, after making this Certificate of Exemption,
you should bactnM aublect %o the Workers Compensation provisions of the
Labor Code.%du must.lorthbwijn comply with such provisions or this permit All roofs shall be inspected prlortoany roofing material being
*Fall be deemed Tevdlied.. .
ii, this 1 n...read his application and it.,.In.,In.above inform.- Installed If a roof Is Inst led Without first obtainingkin.
tion is corracL, I agree-to comply with all city and county ordinances ane Inspection,I re8 t0 fen10V new material f rinapect
nota s of this
atity to building cdhe above
sen, end herebyPr sutbofi r s presem
.leas ws'nit city to Muer upon ins afro ion. and
property for impaction
purposes.
(We) agr. to s indemnity and keep harmless the City of Cupertino
against liabilities, judgments,costs and expenses which may In any way accrue
.Wins%%aid City in consequence of me granting of this permit. SIGN OF APPL A D TE
-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
AD
ItEROOI IMG POLICY FOR '1111; al Y. .01r CU)',GI�TINO 'DUILpING,uL'l An7MGNT
SUUJEC'I.
PRIOR'I'0 ISSUANCI..OF PI;RMI'I' ANb INSI'f:C'flOtJ 1'II�SG.
I. Prior to permit issuance, you nnist agice to cortgtly.tviIICU1BiC, slntldards atid.ptanuPaelruere spec's
oil mool-ilig.
illspectign
tell
lst
2. poin 'll orbo Idin�ii slall pcclorol be A flied iilispckfoii.nlnd aPP�oOaISshill be oblaincdt fronil the,buiiii, ag,.
inspcclor when the iaooGng'is eomPICICd.
1. All lypcs or root sh;tll be ilispcctcrl prior to any toof being iuslnlled. .
4. In older to teccive a limn, you,nn1sl.Coll,plcte steps I, 2„and 1.
I,) Ptcinspcclion or lcacpfi'appioval::
2.p 'Lrprogress insjwclion nPptgyah
1.) l incl inspcc1lon approval:
Opcm.ilc'siiiokcdetector rciificaliat
• b.) :
Sim ilrancstor.ilista IIill'on
5. If plywood is installal, a'pipvood nail inspection is,rcquiml.
(,,' JC :aty rode is"alrplicd withotil,fusl obtaining :m inspcclion, you will be required to remove all new
ntalcri;il doq•n to the sheathing and a building inspcclor trill inspccl allshcalhing al Ilial linre.
WE UNDL•RS`GAND'Tlll AUOVr; POLICY ON REIt0OFING AND WILL COMPLY WITII TILL
POLICY`
IIOMI:UWNERS.NAMI;: t QCEA`B
A})DRESS: :
Rfi11001- G COMPANY NAML: l�
APPLICAN'PS SIGNA'I'URI
CI'T'Y.Olt CUI!LsRI'INO
UUILDING DEPARTMENT
•
Rct oof/tvi n tvoi d