R 3177 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R 3177
b 'REROOF PERMIT - INSPECTION DIVISION PERMIT EXPIRATION
(408) 252-4505 EXT. 228 WITHIN leo DAYS of PERMIT TI NOT
OR
180 DAYS FROM LAST CALLED INSPECTION.
y{ BUILDING ADDRESS BUILDING USE
Zo�B [CXFQI LLf`S RESIDENTIAL COMMERCIAL OTHER
OWNER'S
NAME (00040 , �I,pl�1k `�- FIRE HAZARDOUS
REARDOUS , `tel COVERING
'
AREA A/V CLASS
ADDRESS 2D(9$(2 EXISTING ROOF COVERING _
PHONE 4bO) 28(o 02-5-1 ' NUMBER OF EXISTING COVERINGS I
CONTRAC�T/O�F'/�'S -
NAME "V( L.Ll�1M5_ '�II�'�I TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
CITY&Zsa 1031} (.n� oylCt.1'rs ''e��III°TI 9��l-/n�] L E D IN -
PHONE 0408) - e&(E i 0R UI O 1
LICENSE Lfl 4ogq - �ASPfU/Q-�f SHINGLE
NUMBER WOOD SHAKES lS�v7
L ICENSED CONTRACTORS DECLARATION -
I hereby affirm Chet I em licensed under prgvitions of Chapter B(common
clop with Section 7000) of Division 3 of the Bush..,and Plot...ion, Code, WOOD SHINGLES
and
my license le In full force and effect.
LI.,.ams Cie..- Contra for OTHER (SPECIFY)
Date Contractor
OW N ER BUILDER DECLARATION
I hereby affirm that I am..asap, from the Contractor. Litems Lew for PROPOSED
the following reason. (Sec. 7031.5, Bush.,.and Professions Cotler Any city
or county which requires s permit to construct, alter, improve, demolish,or
repair any structure,prior to Its issuance,also requires,he applicant for such BUILT-UP ROOF
Permit to file a signed statement that he Is licensed pursuant to the provisions G 6
of the Contractor's of the
License Lew (Chapter io % (commencing With exempt
there) - O YIP+ fp�K �Sf�GI�rJ
of m and 3 of the afor th and alleged
eaxem tion.1 or that we is pn.of I moon ASPHALT SHINGLES
from and the applicant
for the sllermi subjects
the
Any violation of section
Tf 31 not o any,t five
bre permit ublect. the eppl¢ent to a civil penalty
of not more that five Hundred dollars my em WOOD SHAKES
❑ I, .i owns or ,he property, or he employe a.with wages ea mein epee
COM
ale
c. will do the work, and the structure is not intended ',offered
Lo sal. (sno apps to Business and of who The of improves
upan.e WOOD SHINGLES
Lew who
not apply [o an owner or property his
builds or improve.thereon,
and who tl v ent work not int or through his own employees, however,
that
such impeoyamenn are not intended or pn.rad b. sale. If, however, tea. OTHER (SPECIFY)
building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for ,q�,p
purpose oe S.I.J. PROVIDE'I.C.B.O. F� DDR -bC199
❑ I, S owner of the property, am exclusively eontreeling With licensed
concise
n isefor$ to c nin uct the project (Sec. 7044, Business and Professions
C„do:ouTtle or improves License Lew does not apply to snow nerofpr-perry PROVIDE MFGRCI NST,/pLMT.ION SPECS..
improves su ant n, andthe ons contactor's Li en such projects Wim a I /al lteV
contract,m licensed punt ant to two Contractor's License Law.
❑ 1 em exempt antler Sec. ,B.&P.C,for this
owner
owner Dere APPLICATION DATE VALUATION PERMIT FEE
'
WORKERS'COMPENSATION DECLARATION PAID p I D
I hereby affirm that I have a certificate of consent,o self insure,.1 a car P M Y
tifi tate of Workers' Compensation Insurance,or a certified copy thereof(Sec. Qo �/'f
Policy Lob.D.I. PR Fit w SEISMIC
Policy Certified
Company ,e/e/,w ^ era
I7Certified copy is hereby furnienad fa993 `/S
Car[itiatl copy is filed with me city Inspection tlWiaion.
Applicant CERTIFICATE OF EXEMPTION FROM WORKERS'
DATE
COMPENSATION INSURANCE. - CI E I JAC�O�MIfSA�
(This action need not be completed it the permit is for one hundred dpb �r ��
Ian(5100)0.In n)
tarsi y t t in [ne partormanca of t} 4 r M1kCh [nia persalt Is
inuatl. 1 all of employ any person li y f , s ea to Paco�e subject -
to m ponsatlon L alit '
Date tr Applicant s
NOT( T APPLICANT: If, e e matin this Certificate.1 E.emption,
you a ultl become subject to 1h Worked Compensation provisions of the
Labor cod., you most forthwith comply with such provisions or this permit All types of roof shall be inspected priorto any roof being installed.To
mall be doomed rev.ked, receive a final I am aware there will be three approved inspections:
I isor that I have rune this application With
and rrand mea the above races and Pre, in ro ress,and final. It roof is applied without first obtaining an
ton certify inept. 1 havagree ro comply ' at a nv a county ordinances end P 9 PP g
state laws relating to building construction, and hereby authorize ropre.en inspection, I agree I will remove all new material for inspection.
Ceti va, of this Cloy t0 enter upon the d keep harve mless
property for Cupertino
Pueposee. D`____
(We) agree s, cave, indemnify and expenses
es Which
the City of Cupertino
against liabilities,judgments,torts and expenses which they in any hey accrue J
apeina aid City in consequence of me granting of sale permit. K2 !T /� /1 eel
ATU
- NRE OF APPLICANT el'f�/,+DATE
J_
•REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS hINSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
I.o. uoM son �
` JUJOU Jurre nvc'ivc Cvjicillnv,CalllvnJa 95015
Cupm161O, Cnlllonda 95UH
Tdcphvnc: )40(j) 752-45U5 '
�•� UEI'nIIIM@Plr Or PLANNING AMU LIMLOWLN17
SUl)1LCT: lul�ooz'xNc POIICX 1011 c7I'X or., cUPLCQxPro DUIIbIPrG bLPl�I17S1LPrl' P11IOIl
z0 ISSUA1 jcc 01" MWdT NID fpISPLCTION "'Mr.
1. Prior to peinlL issuance, you ))Vast- agree to ccnrply
slalxlaads aaxZ nkinufacLLIrea:s speo's on reaoofiaxJ.
7., Plow irooL coveriaxJs shall not be applied r+iLlaauL fir�vEortabA filial.
ii1specui.on alxl wriLtela approval fa:cnn alae humin th ibuil o1Lor
inspection and approval shall be obtained frcaai alae bciildiaxi ittspe
when the reroofiaxg is ocupleLed.
3 . All types of roof . slJall be inspect9d prior Lo ally iroof b"19
installed.
.4 . ill order to receive a final, you Vast ccanpleto steps 1, 2, aixl 7.
1. PrelnspecUon approval
2, Iliprogress i.nspecLion approval
incl inspection appa:oval
a, operable sinoke detecLor 'Yarlficatioti
b. Spark aJ re Lor bist:allaU011
Jr. If .• any roof is applied willaouL
first obt'alt&g an •i]ispectieti, you will
relravo all new ak�terial down to tlae sheaUliiV anti a baildlaxJ �ilspeotor
will bispecL• all s11eatliiaxi at UJat bane.
WE UMDLl15'l'!!ND '1111"s 111�JVL ItiLICX 011 RG[10017NG MID WILL MIMI WI'11l rmir
WLI CX r _ o• �7ori�Ls�+�
c -
I1Ck'1LKh^iNL•'lts PfIIML:
2pb8(P �odeig4£r
laDDnLss
z1LtmMG cors AN x NAME,: 1•J t ` LI A74 s
Api)j ICAtrl'15 5IGNI I-E
czTX o1' CUPLIIf00
• z�uiz,DTPIc DLPnIzzrlLrrr
r