R-3508 (2)C
•
OFFICE COPY
PERMIT
R- 3508
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 WITHIN 180 DAVSOF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
- BUILDING USE
/� v�
S0( 7/);/-
RESIDENTIAL COMMERCIAL OTHER
OWNtERS
OUS ROOF
NAME r /.'Vr tr /� ",, ''��v Lia r /
FIRE
AREA LASS
EXISTING ROOF COVERING
ADDRESS
I/G1��1' CIO
� CI ?V
NUMBER OF EXISTING COVERINGS
PHONE /
TO BE REMOVED TO BE RETAINED
CONTRACTOR
/��I✓VyV/C/!Co/D_
NAME -
TYPE OF ROOF COVERING
ADDRESS
c/ 23aLFe! S %,'i le//1/2—
& Zb
EXISTING
�`��
BUILT-UP ROOF
PHONE
ASPHALT SHINGLES
LICENSE G; (�
NUMBER
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I baby affirm that I am ncenamd Ando IOOf Chapter B (p.
Section ]0001 Division 3 Prof
WOOD SHINGLES
mg with 0l of the Business and (;.do
Busines asslons gods,
and my Ilcehas is and effect _!/ IT/.
Ili cJQ5
Csn .e Cleo Contrtlpctor°r /
OTHER (SPECIFY)
OWNER BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor', License Law for
PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Code: Any city
Or county which requires a permit to construct, alter, improve, demolish,or
Top.i..hy structure, prior to its issuance, also equines the applicant for such
BUILT-UP ROOF
Darmit to to a signed esenmant that he is licensed pursuant to the provitlom
of the Contractor's License Law (Chapter 9 (commencing with Section ]000)
of Division 3 of the Business and Professions Coda) or that he I$ exempt there
ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
]031.5 by any applicant for . permit subjects the applicant to a civil penalty
of not more that five hundred dollars (95007.)'
WOOD SHAKES
❑ I, ss 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 sale (Sac. 70414, Business and P,.fass ions Code: The Contractor's License
WOOD SHINGLES
Law dome not apply t0 on -owner of Property who build$ Or improves thereon,
and who does such work himself or through his Own employees, provided that
..Th improvement. . not intended or offered for sale, u, however, ma
OTHER (SPECIFY)
building or improvement i sold within one year of completion, the owner -
builder will neve the burden of proving that he did not build or improve for
pirtpofao1iele.)'
PROVIDE I.C. B.O. REPORT N0.
❑ 1, es owner of the property, a exclusively convecting with licensed
contractors to construct the project (Sac. 70641, Business and Professions
Code: The Contractor's License Law does not apply to an owner of property
PROVIDE MFGR. INSTALLATION SPECS.
who build. Or improves Inerwn, and who canv.cu for such projects with a
contractor(s) Iicanod pursuant to the Contractor's License Lew.
reason 1 .m exempt gntler S.C. ,B.ay.c. fo. thisAPPLICATION
DATE
VALUATION PERMIT FEE
Owner Date
WORKERS' COMPENSATION DECLARATION
I h.raby affirm that 1 have a certificate OI consent to seltinsura, o
A'
Buildin�
tifica a of Workeri Compensation Insurance, of a ce�ti lied copy theraoI ISec.
3800' Lab. -'en lvi
P{
Seismic
^
T/L�, r/ J•�n//�
t
Pol icy Net
(�
_ / �
rubyC.m
ATyrC tilietl COPY hereby furni$h d.
Carl toad Nt�n}r.gtion tliyision.
JUN 29
yf
1""A�'/l// Total
pv}$ wim.tfl.
Applicant—/�%—I—A�,(��r ^LL
C/
C
C ❑ OF ( ERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS' N.C.
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dols
ler. MIOW or I...) /�
I certify that in In. Performance of, the work for which this permit is e�'
issued. 1 shall not employ any person in any manner so as m become subject
6
to the Workers' Compensation Laws of California.
vjq�
Dau Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
you should become subject to the Wolkoff Compensation provisions 01 the
Labor Coda, you must forthwith comply with such provisions or this Permit All roofs shall be inspected prior to any roof Ing materialbeing
shall be deemed revoked,
Installed If a roof Is installed without first obtaining an
certify that 1 have .ad this application and state that the above inform*
[iDn is C."ect ) .gram to comply with ail city and county ordinances and inspection, I agree to remove all new materials for inspection.
sub laws totaling to building construction, and hereby authorize oprnen
btives of this city to anter upon the above mentioned property for inspection /�
purPoems. /L// / /1
�l�/Yl-/(��///
IWe) agree seven, int*,Co.. antl harmless the City Of 1t
liabilities, xpe ., ..ino
'against mid iyi judgments, costs and expenses which mem in my waY accrue
.wine[ said acv m ronsaggmnpe of m• gaming of mfr permit. SIGNATURE APPLICANT DAM—
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
; 30 '95 01:22Prl VLSI IT DEPT �� Lt (ri �(P P.2/2
L ° �` ., _•- � 3 Sam
Cit-4 of Cupertino
LJ
SMOKE DETECTOR CERTIFICATE OF COMPLIANCE
I understand and comply with Section 1210-a of the Uniform Building Code. ;
Section 1210-a requires when repairs to a single family dwelling exceed $1,000, a smoke
detector will be installed, mounted on the ceiling or wall in each sleeping room and at a
point centrally located in the corridor or area giving access to room used far sleeping
purposes. Ifexisting smoke detectors comply, no new detector shall be required.
I understand the above requirement and certify that we now have sm Ike detectors
installed that do comply.
ADDRESS:
PERMIT NUMBER:
HOMEOWNERS SIGNATURE:
DATE:
0
winword/smkdet