R-3256 (2) PERMIT R_ 3256
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408) 252-4505 EXT. 228 THIEe0cVIN DAvsoPERMIT ISSUANCE OR
ICO DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS BUILDING USE
10033 Hillcrest Road
RESIDENTIAL-X— COMMERCIAL OTHER
OWNER'S
D. Ga6batz HAZARDOUS � ROOF A
NAME FIRE COVERING
AREA CLASS
EXISTING ROOF COVERING
ADDRESS same
NUMBER OF EXISTING COVERINGS 1
PHONE 408-252-6875
CONTRACTOR'S
TO BE REMOVED XX TO BE RETAINED
NAME Heritage Roofing, Inc. TYPE OF ROOF COVERING
ADDRESS 3987 First St. "Pit Livermore
CITY&ZIP EXISTING
PHONE 510-447-7508 BUILT-UP ROOF
LICENSE 595748 ASPHALT SHINGLES
NUMBER WOOD SHAKES 1
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(common
clue, with Section 7000) of Division 0 Of the Business and Profession, Cade, WOOD SHINGLES
and my license i,In�`; yea and effect. 59 748
License Clash 7 -ren)7 Lic.Numbest---;---
Data rrl� Convector Reefing OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law tar PROPOSED
the following reason. (Sec. 7031.5, Business and Professions Coda: Any city
Or County which requires a permit to c nstruel, alter, Improve, dem Olifh,or
tape any nrucmre, prior +o its issuance,also requires ma applicant for such BUILT
LT-UP ROOF
ps= to file a signed statement that he is licensed pursuant to the provision,
of the Contractor's License Law (Chapter 9 (Commencing with Sec,ian 7000)
of Division 0 of the Business and Professions Coda) or that he is exempt there ASPHALT SHINGLES
from and the basis for the alleged mi exemption. Any violation of partially from d any applicant for a permit x bluets the Any em+o a civil penalty
of not mora met five hundred dollen($5001.): WOOD SHAKES
❑ I, es owner of te ProPerty,or my employees with we9m of their sole
compensation, will do"the work, and the structure Is of Intended or offered
for fel. (Sea 7044, Business and Professions Coda: The Contractors License WOOD SHINGLES
Law does not apply to an owner of property who builds or improves thereon,
and who does such work himself or through his awn employees,provided that
such improvements . net intended o offered for sale. If, however, the Firefree Shake
building or improvement r
nt is sold within oe year o, completion, the owner. OTHER (SPECIFY)
but der wit have the burden of proving mat he did not build or Improve mr
pu,poseof sale.). PROVIDE I.C.B.O. REPORT NO. 5075
C] 1, as owner of the property, am exclusively contracting with licensee
contractors to construct the project (Sec. 7044, Business and Professions
oda: The Contractor's License Law does not apply to an owner o,property PROVIDE MFGR. INSTALLATION SPECS.
who bunco or improves theraun, and who contracts for such projects with a T
contractors)licensed pursuant to the Contractor's License Law,
❑ 1 am exempt under Sac. ,B.&P.C.for this
ow�.
r Drs. APPLICATION DATE VALUATION PERMIT FEE
WORKERS'COMPENSATION DECLARATION asUL 10 1995 ,C� r-
I hereby affirm that 1 have .cenificale of consent to sell insure,or a car
- title eta pf Workers' Compensation Insurance,or a Certified copy thereof(Sec. 16000
PolO�icy Np6 1=93 664npan, State Fund Gf!( Ur uur'tHIINU SEISMIC
8 Certified cap,I.hereby furnished.
Certified copy I.filed with the city inspection division.
Applicant
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT VALIDATION DATE
COMPENSATIONCATION INSURANCE
(This ecton need not be
it he permit is for one nu ead doi
ndrl
Ian(SIM artless.)
1 certify tnet in the performance of the work for which this prmit s O -�
issue , snuff not employ any parson in any manner so a ro become subject `7
to the Work. Compensation Laws of California.
Dana Apple.nt
044
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,
You should become subject to the Workers'Compensation provisions al the
Labor Code, you must forthwith comply with such provision,or this permi, All types of roof Shall be inspected prior to any roof being installed.To
shall be deemed revoked, receive a final I am aware there will be three approved Inspections:
I certify that I have read this application , roress,
P9pP an
and state that me above inmrme
tiprein final. If roof is applied without first obtaining on correct. l gree l0 comply with II city and county ordinance,and
.1.1. laws ,elating to building construction, and hereby authorize represem inspection, I e I will remove all w material for inspection.
Iolives of ,his city to anter upon the above mentioned property for inspection
purposes.
li
(We) agree to save, indemnify end keep hotel., the City o, Cu Partin. /
against said
i id Ciiy i j
udgments,costs and expenses f this
they in any way accrue
against,.id City in e.naegq.nee.f the granting m,his permit. /d
SI RE OF APPLICANT DATE
REQUIRED PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY