R 3850 (2) PERMIT R_ 3850
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
(408) 252-4505 EXT. 228 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING �NG USE
ADDRESS --gyp,,,, � IyJ BUJ
`" � 800 ) f 29���"I e ! 0 RESIDENTIAL COMMELD'RCIAL OTHER
OWNER'S
,HAZARDOUSROOF
NAME6mne,brl 'dde. HCp� d ?wA FICOVERING �•
GG / AREA CLASS
ADDRESS S-yz;r P. (�'�� EXISTING ROOF COVERING
PHONE 'go S I —(0 �-- NUMBER OF EXISTING COVERINGS
CONTRACTOR'S Casto Roofing Inc.
TO BE REMOVED TO BE RETAINED
NAME 1988 Old MiddlefieldTYPE OF ROOF COVERING
ADDRESS Mountain VOWS CA 94043-2503
CITY BI ZIP EXISTING
PHONE (PGGat b7ZZ
BUILT-UP ROOF
LICENSE %Zq� ASPHALT SHINGLES P A I D
NUMBER cl / WOOD SHAKESI�'J1�(�0 ���
LICENSED CONTRACTORS DECLARATION JUL � AN
Ihereby affirm that I am licensed under provisions of Chapter B Icommen-
cinp with Section ]000) of Division 3 of the Business and Prpf...lips qq., WOOD SHINGLES rally
and ms'lic n Is in 1 11o' effect. if 2 li 1 Ur uurGn 1 ur1.J
LI<em.Cl
Conic.Number_ l OTHER (SPECIFY)
De»�— Contractor
O§VN1R-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor'. Liunse Law for
the following rUsop. (Sec. 7031.6, Business and Professlpns Cnds: Any city PROPOSED
or county which requlrss a permit 10 construct, alter, Improve,demolish,ur
repair any structure,prior to Its Issuance,also requires the applicant for such BUILT-UP ROOF
permit to fila t signed statement that he(Chapter (come pursuant t0 the provisions
of ms Cont rector's License Lawlot... . (commencing or hot wi tis Section 7000)
of m and
3 of the easiness and ged exem code!or y v he IS exempt therm ASPHALT SHINGLES G
from rad the best* for the alleged exemption. Any violation of Section
]031.6 by any ePpll..nt,or a permit Wblacts In. applicant to a civil penalty
Of rapt mora the,five hundred dollar.($600).): WOOD SHAKES
❑ 1,as owner of the property,or my employees with wages as their Sol. /e
compensation.will do the work, and the ens Code is not intended ',offeree WOOD SHINGLES
for life(Sea 7044, Businns and f properly Code: TM1e or impr ve$ hereon.
Law don not such to an owner 1 progeny who n em or employee,,
pros thereon,
and who eon such work not int or through his own am.I., If. however,
[her
such Impro,v Monts are not intended or offered for $aloe If, however, the OTHER (SPECIFY)
builtli rap 0r improvement is ..to within on. year o, complalion, the owner
builder will have the burden of proving that he did .01 build or improve for
purPOu of sole.). '
❑ I, a. own., of the property, em exclusively contracting with licensed PROVIDE I.C.B.O. REPORT NO.
contractors to con erruct the project (Sec. 7044, Business ..it Profusion.
Coe.: The Contractor's Li..n.e Law does not apply to an owner of property PROVIDE MFGR. INSTALLATION SPECS.
who builds or improves thareun, and who contracts for such projects with e
contractor($)licensed pursuan,to the Contractor's License Law.
❑ I am exempt under Sec. APPLICATION
,or this
lessoheli n
Ow Da
WORKERS'COMPENSATION DECLARATION Building
I hereby affirm that 1 nrve a certificate of consent to..If inmra,or•car
tilican o,Works a'C/o.E9/p I .b$mnn,or a/w�nifnietl copwy thereof ISac. _ /]/J $elamlC
3800. of
105 a 5" !/�� /KILN/V r t •-10 p��OO
PinigNo. ompanv
/1.Carolled Copy if hereby furnished. Total
o Certified Co lilae witra tupi city'mpution dw,.ion.
Applicant / IAA 1'1_l1Yr+s's
CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT AUTHORIZATION DATE
COMPENSATION I NSURANCE N.C.
(This section n_d not be completed i, the permit is for one hundred deb
long($100)or less.)
I certify in., in Me 1.0tument. o, the work ,or which this permit is
issued, I .hell not employ any person in any manner so asto become Subject
to the Workers'Compensation Law,of California.
Data Applicant
NOTICE TO APPLICANT: If, attar making this Certi,ic.ta om
f E.eption,
You should become sublec, to the Workers'Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
Shall be od All roofs shall be Inspected prior material being
mad must . pecp oan Y roofing mag
..rat, that 1 In...r.ad his application and star.In.,In.above informA installed If a roof Is Installed without first obtaining an
tion is correct. I .grin td comply with all city and county ordinances and re
Rab law. roofing to building construction, and hereby authorize repletion. jna Pactio n,l agree to remove all new materials for inspection.
tetivn of this city to onto upon the abov.-mention.d Property for inspection • ^��
to
(We)liabilities,acne ane, In t,cos, and kee,Pa ,$ mingwhich tis. in a of ay ccciu.
*palml saidyi judgment,cpm and upam_watch they on any wry eccrv.
swim,$Sia City in<onseap.n<e of the granting o,t0).oa.mit. SIGNATURE 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