R-6539 PERMrr
APPLICATION FOR CITY of cuPERTINo
NUMBER R- 6539
INSPECTION DIVISION. PERMIT EXPIRATION
REROOF PERMIT (408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM UST GALLED INSPECTION.
BUILDING ADDRESS
D33Z ':bl�V VY(-/ �1 ' RESIDENTIAL•
COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
P YES ❑ Ityes—I uttlerstend that a Class A
NAME root asseMNy is required.
NO ❑ Initlal I.C.B.O.Y
ADDREss r I EXISTING ROOF COV'EERIN�G/].
NUMBER OF EXISTING COVERINGS
PHONE
CONTRACTOR's TO BE REMOVED t�N) TO BE RETAINED
NAME 1/C C�1�X� ✓VLl I rrA� V� Ute'
ADDREss /_ A L TYPE OF ROOF COVERING.
CITY&ZIP— (/�L l� I U V1
V 1 I
4I N
PHONE `'' I — t !' '1 L/ BUILT-UP ROOF ❑
LICENSE ' ^2,� ;SPHALTSHINGLESNUMBER Lw ❑LICENSED CONTRACTORS DECLARATIONI hereby affirm Met I em licensed under provisions of Chapter 9(commencing with Section OD SHAKES
7000)of Division 3 of the Bustaess arW Professions Code,and my license le In full torte entl
effectA. D SHINGLES ❑LicenseI C.lose`-� Lb.Number Dale I(l Centrad« u� PEC ❑OWNER-BUILDER CLARATON pROSED
I hereby affirm that I am exempt from the Contractor;License Law for the blowing reason.
(Sec.7031.5,Business arts Profasmo s Code: Airy dry a county which requires a permit to
construd,altar Improve,demolleh,or repels arty structure,prior to Its Issuance,also requires the BUILT-UP ROOF Elappncent for such permit to he a signed statement that he Is licensed pursuant a the provislons
of the Contractors License Lew(Chapter 9(commend g with Sedloa]000)of Division 3 of Me
Business and Profeselara Code)or that he is exempt Therefrom and the basis for Me alleged! ASPHALT SHINGLES ❑
exemption.Any vbletbn of Section 7031.5 by any applicant for a permit subjects the applicant to
a dull penalty of not more than ave hundred coears(§500).1:
❑I,as owner of the property,or my employees with wages as their We compensetlon,will do WOOD SHAKES ❑
Ute work,end the structure is not intended or offered for able(Sec.7044,Budllese and Pmfe.-
.Ions Codeclola Li
:The Contracense Law does not appy to an ovmer Nproperty who bullde a WOOD SHINGLES
Improves thereon,end who does such wok himself or through his own emplyah s,provided that
E]
such improvements we net Intended or offered for safe.If,hovrever,Me building or Improvement
Is sold within one year of comptsfion,the ownervbulber will have the burden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of Si - ld
❑I,as owner of me property,em exclusively contracting with licensed contactors to construct
the project(Sec.7044,Business and Professions Code:The Contractors Uconse Law does not PROVIDE I.C.B.O. REPORT NO. "1"I'7✓
appy to an owner of property who bulas or Improves thereon,and wbo contracts far such projects ,
with a contractons)licenaed pursuant to the Contractors ucari Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm unser penalty of perjury one of the following decLani
I here and will maintain a Certificate of Convent to sett Insure for Worker's Canperaat on, rrr///��� Ulldln [Jyyy /y
lee mit Is is for M Section 3700 of Me Labor Code,for the performance of Me work for wMch MIs I /,/ {/)�}� � 1 ./- I l�
Permit is vetted. l..S� (J) /•'` I / / elsmic
{�fi�ftt have and will me pert Workers f the wort,
Jon Insurance,as repulsed by BBdbn ores of /
mbar Cade,f«Me pedortrarob of the vrtxk br which Mls partnit ts tseuetl.My Workers / C
Compen�satllon Ineumnca carder en�tl�POI�`�'number ere: Total t/ y
Ca...erZ,7.7�t � �'V-�VIC1 Pdbi'No. !!�I 3- PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE N.CQ
(Thls section need not be completed If Me permit Is for one hundred dollars($100)or lass.)
1 certify Met In the performance Of the vxork for which this perMt Is lesued.I shell not or Iq
any person In any meatite��so e.to become subjed/�to the Worker/e'Compensation Laws rof,��i. All roofr.shall be inspected prior to any roofing material being
Datfame. f .�GfiGGc,�G�cCQ, - /OGUO� installed. If a roof is installed without first obtaining an
Dela _' Applicant inspection,I agree to remove all new materials for inspection.
NOTI TO AP UCANT: If,after making this Certlgrate of Exemption,you shouts became Applicant understands and will with all non
subject to Me Workers'Compensation provisions of the Labor Code comply you must falhwith comply. App p y point
wlm auch provisions or MIs permit shalcbe deemed revoked. .source regulations.
I cenity that I hale read his application and state that the above Inbrmadon Is correct.I agree
to comply with an dry and county ordinances and Nate leve reLfi to bulking alnstructbnanal All roof coverings to be class or better. )))
hereby eulhodie representstivea of this dry to enter upon are ebava mentlenetl property br In-
purpose..
I (We)
(We)agree to save,Indemnify and keep harmless the City of Cupenlnoegbinst Ileblldes,
t; '
judgneri cosand expenses accrue CA
may In eery way aragainst and!Gy In consequence SIGNATURE OF APPLICANT DATE
of the granting of this Permit.
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 ACCESSTO ROOF SHALL-BE PROVIDED FOR INSPECTION
• OFFICE COPY '