R-6648 PERMIT R_ 6648
APPLICATION FOR CITYCUPERTINo NUMBER
INSPECTION DIVISION MI EXPIRATION
REROOF PERMIT
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED'
WITHIN S F DAYS S PERMIT ISSUANCE O.
t 180 DAYS 0 DAY LAST CALLED ISSUANCE
CION.
BUILDING ADDRESS
Do(o C.�C,[✓N1c, Q�LV� ; X
RESIDENTIAL COMMERCIAL OTHER
OwNER'S HAZARDOUS FIRE AREA
NAME M l rn (' A Q L�'o 0YES ❑ h1yes-I ur,aerelarw Irlat a ClassA
mof assembly is required.
NO ❑ Inflal I.C.B.O.R
ADDRESSoc)(60—z— /Z��G��fl,C "&'y D- EXISTING ROOF COVERING
PHONE / J� lJ Z-+� _ NUMBER OF EXISTING COVERINGS '
CONTRACn R'S -
NAME Mr-3fk NC.f, (`iG Vp .. TO BE REMOVED I TO BE RETAINED
ADDRESS n p TYPE OF ROOF COVERING
CITY&ZIP 22\Z I���LA� A�7�. ; ��], 1512 -
�l - EXISTING
(,y
PHONE ' 1% —0G�-I BUILT-UP ROOF -❑
LICENSE 156LA— iSC ASPHALT SHINGLES ❑
NUMBER
LICENSED CONTRACTORS DECLARATION
I hereby aumm that I am Ilcennof under provision of Chapter a(commencr with Section WOOD SHAKES
700D)of DMelon 3 of the Buslnese end Prole$$bra Code,and my license Is In full force antl
eHest.
Llcwse Clave tic.NumberWOOD SHING
9:G,0 ]n\
Date �G ContrecmrA,4-SAA6AOTHER P SPEC zr—J
�trG (
OWRJER-BUILDER DECLARATION PROPOSED 6 �CJ99
I hereby 7031. ,Buirm Net am exempt from the e: Any city or county
Lew for Me-Irefollorp r eon. JUL
(Sec.]031.5,Business and Professions Code: Arty city or count'wlrbh requiremil to
construct,alter,knprove,demolish,or repair Bary structure,prior to Its issuance,also Srap e$the BUILT-UP ROO ❑
applicant for such permit to Hle a signed statement that he Is licensed pursuant to alone
of the COnirector'a Llcensa Law(Chapter B(commandng wish Sactlon]000)of D 3 of the
• Buark,as and!Professions Code)or that he Is exempt Harefrom and me heel. ed ASPHALT SHIN 1 6
exernptlon.Any v'IoIatlw of Seclfon 7031.5 by any applicant for a permit subjects a o
a clAl penaly of not more aan five hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their ads compensation, 111 AV .WOOD SHAKES 0
the work,and the structure is not Intended or offered for sale(Sec.7044,Bus] ,"and Proles-
. dans Code:The Contractees License Law does not apply to an owner d property who bulltle or OOD SHINGLESE]Improves theron
e ,amd who does each work himself or through Ns own empbyms,provided that
each Improvements are not Intended or offered for safe.H.howerer,Ne bulking a Impravemera
Ie sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑
nat build or Improve for purpose of sale.).
❑I,as owner of the property,am exdusWty contracting with licensed contractors to construct
the project(sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who build$or Improves thereon:and who contracts for such projects
with a ContInl Icensetl pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B&P.C.for this reason
owner oefo APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
hereby a nd under gamey of penury one of the lto serf4r duro for w: C
❑ have and wti1 maintain a of Me Lab of Consent to eperInsure for Wohe work
Comp which
on, Buildin
'
as provltletl M by Sectlan 3]00 of iha Labor Code,for Ua performance of the work for whlth Nle c ss g
permit is issued. -7-6 —15 j �3 CIJC) seismic
ltfl have and will maintain Workare Compensation 11k,wkfor I hick this as required by Sedlon Workers s ���fff f 9 !!
Co boa Code,for the performance of the ware for which ihl$permit ts Iseued.My Workers esu-r 519
Compensation Ineurence senior end Pdlry number are: � Total
Carrier SLlld IiNDVA tN$VUWC�Iky No. WC2=OG-74}CV4 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NO)
o �f Z
(Thio vection meati not be completed If the penNt le for One hundrotl dollars(f 100)or Ins.)
I cerlHy that In the performaroe of the work for which Ins permit is Issued,I shall not employ
any person In any manner so as to become subject to Lia Woreeaa'.Compensation Laws of Can- All roofs shall be inspected prior to any roofing material being
Tomb. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this CartlHCale of Exemption,you shwa become Applicant understands end will comply with all non int
subject to the Workers'Compensation proN$Ioaa of tla Labor Coale,you must forthwih corn eft' P Y Po
with such provlslwe or this permit shall Ee deemed rel source regulations.
I certly that I hors read this appllcation and state that the above Information Is mrrect.I agree
• to comply with all Clty and county walnances and state laws rolaung to building censtructlon,and All ro cos rings to beplla/_ss fhOr better.
hereby authorize rwreewtethree of this city te enter upon mOovar�ntlonetl property for In- ��/ +�eb ��
hereby
purposes..
(We)agree to sere,Indemn and keep hem mums the C of Cu Nw against lablllun,
judgments,wets and expensas"Id,may In any way accrue against mid City In mneequence
If Ha Warning of this permit 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