R-6217 PERMIT
_ NUMBER R- 621.7
APPLICATION FOR CITY of cuPERTINo
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT - ,(408)777-3228' PERMIT EXPIRES IF WORK IS NOT STARTED
_ WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ If yes—I UncIOMtmnc Ihet a Class A
NAME roof assendAy is required.
I - - NO ❑ Initial I.C.B.O.O
ADDRESS—
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTO /
_ TO
NAME—
BE REMOVED r TO BE RETAINED
'k^ ' C/ _
ADDRESS y/J p / TYPE OF ROOF COVERING
CITY&DOM ""`�ti /L` '
' EXISTING
PHONE S/-0 q/q — 7/9,?Z BUILT-UP ROOF ❑
LICENSE O I/ ASPHALT SHINGLES
NUMBER 6 ❑
LICENSED CONTRACTORS DEGJrRATION
I hereby affirm that I am licensed under prcnrfl a of Chapter B(commencing with Secdon WOOD SHAKES
70(0)of_DMabn 3 of the Business and Proleselons Code,aro my license D In full force and
effect. `QWOOD SHINGLES ElUcers f Clee Dc.Number
Date 1 / Convector OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm Met I am exempt from the Coniractole License Law for Ma ktllowing reason.
(Sec.7031.5,Buslnase and Professions Code: Any city or county which require,a gem it to
construct,alter,Improve,demellSh,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such Permit It a Ills a signed r 9(cm m that g Is licensed Pursuant to the Pro Of Me
of the Conor suchs Ucenso Lew(Chapter 8 statement
at h with Section]000)of o the
3 0l The
Business and Professions Code)or Nat he Is exempt Therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exemption.Any ve4abon of Section 7031.5 by any applicant for a permll subjects Uta applicant to
e civil penalty of not more than live hundred dotlam($500).)
❑I,as owner of the property,or rtry empkryeee wffh we a Irede compeneetlon,will tlo WOOD SHAKES ❑ _
Me work,and the structure la not Intended or offered for Business and Proton.
elone Calle:me Conirector'e license Law dose not apps f owner o _ arty wfw balms or WOOD SHINGLES ❑
Improves thereon,and who does each work hlrrteeif o Lv aw I wide,Net
such Improvements are net Intended a offered fon eel er, p or overnent
le Bald within one year of canplatlon,the
.or
to vdwnavetheburden proving ala OTHER(SPECIFY) IS(I I'tiI/r'Uti
not build or Improve for purpose of sale.).
❑I,as wvner of the property,am exclueWeVy ce Ing with licensed conmecl cons ,�,y�
the project(Sao 7044,Business and Professions ode:The rontractofi Lbknee LewI
PROVIDE I.C.B.O.REPORT NO. E 90 -3
apply to an Owner of property who builds or lmpr reon,entl who conhdde for ru
wITh a contractar(e)licensed Wrsuent to the Co a ucerse Law. /vf yp
❑ em axempl under Sec. ,B 8 P.C. 0PROVIDE MFGR.INSTALLATION SPECS.
°cone` APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECIARATI
I hereby affirm under penally of perury one of the following declaration: d❑ have entl w01 melnlaln a CeNncate of Consent to eeHansore for Workers BUlldln /�ee poviOetl lOr by 9actbn 3]OO OI the Labor Cade,for the peMrrrance of The work tor1141x, /, /360 SBISri11C
per h Issued. 77
hwa and wiii maintain Workers Compensation Insurance,as required by Section 3700 of
ih Colla,for the pedomnance of the went,for which this permit is Issued.My Workers y r 3 e
Compensatl Insurance;terrier antlp�{cy number are: Tota [_�
Carder � Sit u Policy No. d�c1/�S 2� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not be completes If the permit Is for one humored collars($100)or Ion.)
I certify that In The performance of the work for which this permit a Issued.I shall not employ L Y"
any person In arty manner so m
se to become Subject to the rice e'Companeet on Lew,of Call- All roofs shall be inspected prior to any roofing material being
fo`r'te. Installed. If a roof is installed without first obtaining an
Date V O t 9 Applicant' inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this CerfifficatI6 of Exemption,you should become Applicant understands and will comply with all non point
subJact to the Workers'Compensation provisions of the Leber Code,you must fomThwlih comply
with such provisions or W,Permit MaSbe deemed revoked. Source regulations.
1 certify that I have read Nb application and state that the above Information Is oomrect.I agree
to comPy with all cm,and county ordinances and state Tawe relating to building conetmction,and All roof cove 'ngs a class' or better.
hereby authorize representatives of MLS city to enter upon the above-mentioned property for In-
(We)agree to cave,indemnity and may
I harmless the City of st petal Ci y In con liabilities, (.y..�
of Me gran cogs entl permIL ee which may In any way amus ap4lnst eels Gry In consequence
of Una Q,ntingdihls permit SIGNATURE DAPPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
.INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DATEINSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY