R-6161 PERMIT R_
APPLICATION FOR a�jb� 1 NSP O CUPERTI NO NUMBER M tPl 6161
REROOF PERMIT �� (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESSJ /
/�/ �� ' " �� ��• ! vv ` RESIDENTIAL COMMERCIAL OTHER '
OWNER'S HAZARDOUS FIRE AREA
_ YES ❑ If yes—I understand that a Class A
NAME- roof assembly is required.
NO ❑ Initlel LC.B.O.N
•ADDRESS S Vb1 Q, - EXISTING ROOF COVERING
PHONE `["`•�' NUMBER OF EXISTING COVERINGS
CONTAAC/jOR�'xSr /'A 1
NAME (-f/&QI/.cyi /Trill - TO BE REMOVED TO BE RETAINED
AeoDDRESS ' TYPE OF ROOF COVERING
CITU 8 ZIP - x
EXISTING
PHONE BUILT-UP ROOF ❑ -
LICENSE //
NUMBER .ASPHALTSHINGLES - El
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am Ilcen ted under provisions of Chapter 9(commencing with Section ODD SHAKES
7000)of ONlslon 3 of the Business and Professions Code,and my Iicarwe is In full force and
effect. 8/y] c��7 W SHINGLES ❑
License Cleve Llc.Number
Date contractor OTHE IFY) ❑ .
OWNER-BUILDER DECLARATION PROPOSED.
hereby alllrm that I am exempt from Me Contractors License law for the following reason.
(Sec.7031.5,Busineas and Professions Code: Any city or county wh4h requires a permit to
canlff, L atter,Improae,demolish,or repair any Structure,prior to lb lesuanca,also requires me BUILT-UP ROOF
appicam ler such permit to life a signed statement met he U Iioensed pursuant to the prcv sic e
of the Contractors License Law(Chapter 9(mmmendng 001 wlm Section 70of Divbkxr 3 of me D
Buslrmes end Professions Cade)or that he is exempt therefrom and the heels ler the alleged ASPHALT SHINGLES
�- exemption.Any Aolatlon of Section 7031.5 by any applicant for a permit Subjects the eppibanl to
a cMl penalty of not more man five hundred callers($500).): L 131999 31999
❑1.a owner of the property,or my employees with wages as their Sale compenseibn,will do WOOD SHAKES
IN work,and the structure IS not)mended w offered ler sale(Sec.7044,Business and Pmfas. -
alons Code:The.Contractors License law dove not apply to an owner of property who builds or WOOD SHINGLES ❑
Improves thereon,end who does such work himself or through his own employees,provided met By
such Improvements are not Intended or offered for Bele.If,howeveg the bulding or Improvement
Is sold within one year of completion,me owner-builder will have me burden of proving that he old OTHER(SPECIFY) El
bulk or Improve for purpose of sale.).
❑I,as,owner of the property,am exduelveiy contracri pwith licensed contractors to construct
the proisd(Sac.7044,Business arm Professions code:The Contradore Ucense Law core,ret PROVIDE LC.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon,end who contracts,ler such projects
with a co ntractor(s)licensed pursuant to me Contrador'e License law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 em exempt under Sec. ,B&P.C.ler this reason
owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION A
I hereby affirm under penalty of perjury one of me follovmq declaration:
I have end will maintain a Carl of Consent to self-Insure for Workers Compensator, Building J`
as provlced for by Section 3700 of the Labor Code,ler the performance d the work for which MIS
permit le leaned. /:� Seismic
❑I have end will maintainprt rmancWorkers Compensation I which
this as required by Section 370001 �G1/ q fy
Jho Labor Code,for the padarmance of me work for which thio pemMt le leauetl.My Workers �'� f 2 OC Total l•T�
-Compen on Insurance center entl Policy nuAxm�be��r are: q�
Cerner •I�d,►uU.L cT�!'b- -CJ7. policyN,(�,1c� QgB?J73X PERMITAUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ ,
(This section need not be completed II the permit Is for one hundred all($100)or less.)
I certify that In me performance of me work ler which this permit b Issued,Ishell not employ
any person In any manner So as to become subject to the Workers'Compensation Laws of Cell- All roof II be inspected prior to any roofing material being
ftl instaAd. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
SWIM to theDWorrkers Campereebon provi INS
of tiheI-abor of
yyounre sstforthwithco They Applicant understands and will comply with all non point
with such provision or this permit,helpbo deemed revoked. Source regulations.
ve
I certify Met I neread MIS application and State that the above Information Is coned.I agree
to conI with all city and county ordinances and state levee releting to building construction.and All roof Cover gs to be class"C"or better.
hereby purposes.
urpo a representatives of this dry to enter upon me ebo-re-mentioned property ler In- ��
epedbn agree to
(Wel agree to save,Indemnity erM keep hermiese the Cly of Cupertinoegaequ
lnet Iiadlltlee,
lu nts,costs and expenses which may In any way accrue against eek Cly In coneerx�
of a g granting of mm perms. SIG OF AP A DATE
PRE-INSPECTION:, PLYWOOD: IN-PROGRESS:
INSP, DATE INSP, DATE INSP. DATE
TEAR OFF INSPECTION: - BATTENS: FINAL:
INSP. DATE INSP. '-DATE )NSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY