R-3583 PERMIT 3583APPLICATION FOR CITY OF CUPERTINO NUMBER R
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)252-4505 EXT. 228 ORK IS NOT STARTED
WITHIN EXPIRES S'of PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
_.• BUILDING ADDRESS BUILDING USE
19736 Auburn Drive RESIDENTIAL X COMMERCIAL OTH
OWNER'S
David Johnston HAZARDOUS ` `a COVERING
ROOF
NAME `�.J
AREA CLASS
ADDRESS 4290 Emma Jane Ct. , Beaver Creek, 0h.4544 EXISTING ROOF COVERING
filglegal
PHONE 513— 427— 4724 NUMBER OF EXISTING COVERINGS 1
CONTRACTOR'S TO BE REMOVED TO BE RETAINED
INAMESecurity Roofing, Inc. TYPE OF ROOF COVERING
ADD ESS P. 0. Box 2450, Menlo Park, Ca. 94026 EXISTING
PHONE 408-947-8811 BUILT-UP ROOF
LICENSE ASPHALT SHINGLES
NUMBER 5047 WOOD SHAKES X
LICENSED CONTRACTORS DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9(comm..
Final with S«Hon ]000) of Division 3 of the Business and Profanionf Coda, WOOD SHINGLES
and my license Is In full to it affect.
Lice ClAr L.lY Lic.Number 306.844
Date (� Contract.`et77PZTl�F�DTZTICI—iT1C OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Conv..ld,s License Law tot PROPOSED
the following reason. ISec. 7031.5, Business and Profession,Code: Anv city fT.
Or County whim requires a Permit to construct. alter, improve, demolish,., LY
repair any structure,prior to its issuance,also requires the applicant for such BUI LTIy�ROO
Permit to fila a signed+...amen,that he a liun. t to tn.proviy 1N F
of the Contractors License Law (CMp[ar-B Icer ucingnwi,n Saborur000) ea 2
.f Division 3 of the Business sena Professi s 1. net M1a i+exemp( era" ASPHALTHINGLJ�S
from red the basis for the all, axe ,i e y violati f ��1I I ('��
7031.5 by any applicant for a parmi[sob spplicent 10 it pe Ity Fvff f (fl-
of not more roar flys nun ed do 50 WOOD SHAKEStH11NQ
I,as owner of the . t tela n vRapas a+t air+aa
<om❑pnation,soul eo - r 'n me f��crvre .aneae or onered WDDD SHINGLES
for ilia ISa<. ]044, Basin t d I rofess otl M1 C n,rac,oi s Llcanse
Law does not apply to an er of p oPart improves thereon,
and sono e.es wFn work him If.r m5pu own.mPlovee,.pm.ie.e that 1 21l 1 30# felt 40yr
such improvements are no, in,anded rpt ed for sale. It, however, the OTHER (SPECIFY) / P > +
building or improvement is told wiNl Dna year of completion, ,M1a owner ass k
buil Car will nava the burden of proving that he did not build or improve for
purpose of sole.I. PROVIDE I.C.B.O. REPORT NO.
❑ 1, a of the property, a exclusively contracting with liunsad
Contractors to construct the project (Sec. 7044, Business and Profession%
a:
CodTheContractor'sLicenseLawdoesnotapplytoanownerofproperty PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thawun,and who contracts for such projects with a
cont ractor(s)licensed pursuant to the Contractors License Law.
❑ I am exempt under Sac. ,B.&P.C.for this
reason APPLICATION DATE VALUATION PERMIT FEE
Owner WORKERS'COMPENSATIONDECLARATIONDate Building 123.00
1 hereby .'firm that I have a certificate of consent to self-insure,o �[
tific*te of Work.,.Compensation Inwrence,or certified COPY thereof(Sea 10/17�JJ (1NY1 M Seismic .90
Polio,Lob. 5-285-&b State Cow. Ins. Fund TMl W
Polley Certified
Puny 123.90
pq(ondi.e F.pv b n...br wmi+n.e. Total
Applicant titiad copy is filed w' to i ctio6i�•;or,.
CERTIFICATE OF EMPTION FROM WORKERS'CNC O PERMIT AUTHORIZATION DATE
COMPENSATION INSURANCE
(This action n d not be Completed if the permit is for one ob
hundred d
let.l
$1 DO)or ret.) 1`
I certify that i the performance of the work for which to is permit is
wad, I null of ploy any person in any manner so as to become subject
1.'heWOr pensrtmn Laws of Calif...I..
Data m Plican,
NOTICE TO APP LIGAN 11,
attar making this Certificna of Exemption,
You should become subject to the Workers'Compensation provisions of the
Labor coda, you must forthwith comply with such provisions or this permit All roofsshall be inspected prlortoany roofing material being
shall be deemed r.y.k.d.
1 certify mat 1 hay*reed this application and state that the above informs Installed If a roof is Installed without first obtaining an
tion is correct. I agre to comply with all city and county ordinances and inspection,I agre SO rem. 11 new pia are aforinspeetion
state laws relating to building construction, and hereby authorize rapraam
tatives Of this city to enter upon the above mentioned property for inspection /
purpmes
(Wal agre* s. saxe.udg indemnify and keepexpenses
harmless the in a of ay accrue Nf �?
against liabilities,judgments,costs and expanses which may in my way accrue
.alaim.said City in consequence of the granting of this Permit. SIGNATU -ic"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 COPY