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Job Date
Company Name
Name
Phone
FAX
Street Address
City
Type of Roof (check one) Composition Wood Shake Wood Shingle Tar & Gravel Tile Cap Sheet
Other
Pitch 4/12 5/12 6/12 7/12 8/12 10/12 12/12
Number of Stories
Number of Squares
Roof Layers 1 2 3
Gutters stay remove
Roof Jacks stay remove
Accessibility ground drop direct to building
