R 6010 1 � -
, • PERMIT
APPLICATION FOR ciTv oF cuPeaTiNo NUMBER R- 6 010
REROOF PERMIT INSPECTIONDIVISION PERMITE%PIRATION
i �4OB�7TI�.�PZB PEFMIT EXPIRES IF WORK IS NOT STARTED
. WITMIN 1B0 DAVS OF PERMIT ISSUANCE OR
1B0 DAVS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS �
G / � � � KJI.f.� � �' K • RESIDENTIAL � COMMERCIAL OTHER
OwNea'S � t�f � HAZARDOUS FIRE AREA -
NAME v �� e -s� v LL Ci YES �• raofassem6y s�aen�d'h�a1�a Class A
/� ��, // NO ❑ Initial I.C.B.O.N
nooaess ��Z�7 wu �n � /'FX ' EXISTING ROOF COVERING
PHONE �� �+ _ • �� _ 7 �'+ NUMBER OF EXISTING COVERINGS �
CONTRACTOR'S '
C TO BE REMOVED � TO BE FETAINED
NAME w( O l ``�-^t
ADDRESS �.,,c � TYPE OF ROOF COVERING �
aTv a na .3 �v ,i / '
-�', �f,YaB' EXISTING
PHONE_�,�,e �,�� � �� BUILT-UPROOF ❑
NIUMBER 'Z 3 ASPHALT SHINGLES
❑
LICENSEO CONTRACTORS�ECLARATION
1 hereby eRl�m thet I em Ilcenaetl untler provlslane ol Chepter 9(cammencinp with SecUon WOOD SHAKES �
]000)ol Dlvlsion 3 0l tha Buslneea entl Proleaelone Cotle,end my Ilcanea le in full lorce entl �
enec�. WOOD SHINGLES ❑
UCenee Clee Lla Number L L �
oete � comrecmr OTHER(SPECIF`O ❑
OWNER�BUILDER�ECLARATION � PROPOSED
I M1ereby eHbm thal I am eMempt Imm�he Contractote Licenae Lew for t�e follow r e
(Sec.'l031.5,Buelneee antl Profeeelane Cotle: Any clty or counry whlch requlrae erm �
conevucq alter,Improva,Eemalleh,or repelr eny etmcture,prlorto Ite leeuence,elso repulree ihe BUILT-UP ROOF � '
appllcent Mr euch permlt to ille e elgned etetemant ihat he la IlceneeE purouent to the provlelone -
. ol ihe Contrector'e Llcenee Lew(ChaD�er 8(commenclnp wlth Sectlon 7000)ol Divlelon 3 0l the
Buelneee end Pmleealone Cotle)or Ihet ha Is axam0�therefrom entl the Ceale Mr Iha elle9etl SPHALT SHINGLES �
e�amptlon.Any vlalellon ol Sectlon 900t.5 Ey any eppllcant lor e permlt eub�ecto t�a eppllcent to
e clvll penelty ol no1 mom Ihan flva huntlrotl tloltare(5500)J:
�I,aeowneroltheproperty,ormyemployeeewlihwepeeasihelieolecompensellon,wllltlo WOODSHAKES �
the wo�k,end the etrucWte le not Intentled or oiferetl tar eele(Sec.7049,Buelne6e entl Profee�
elone Code:The Contmctor's LlcenSe Lew tloea nol epply lo en awner ol pmperry w�o bullEa or yy00D SHINGLES �
Improvee therean,entl who tloee euch work�Imsell ar Ihroup�hle own employeee,proNGeG ihat
. suc�Improvemenle ere not Intantletl ar alleratl for eale.II,however,lhe Culltllnp or Improvamant
Ieeoldwlthinoneyaerolcom01e11on,theownao-bulitlerwlllhavalhaburEenolprovinpt�et�etlid OTHER(SPECIFY) �
not bulltl or Impmva lor purpoae ol seleJ. ,
❑I;eaowneroitheproperry,ameMCluelvelycoNmctlnp withlicenaeticontrectaretocone_([uct
' the pro�ect(SecJ044,Bu6lnesa entl Pmfeeslona Cotle:The Conirecrofe Licenea Lew Qoby"t�ot PROVIDE I.C.B.O.REPORT NO.
eppty to en owner ol properry who bulltle or Improvee t�ereon,entl w�o conirectq(p_r a�Ch pro�acte
with e contrectar(e)Ilceneatl pureuent lo Ihe Conhector'e Ucense Law. Fj . PROVIDE MFGR.INSTALLATION SPECS. '
❑I em exempt untler Sec. ,e d P.C.br Ihle a S
owner oete APPLICATION DATE VALUATION PERMIT FEE
N/ORKER'S COMPENSATION DECLARATION ���.
I hereby eflirm untler penelry al perlury one oi the lollowlnp tlecleretlon: ., �
�I�eve entl wlll malnteln e Cortlllcete ol Coneent to ealf�lnsure IorWar �'@ pampenaetlon, Blllld'Ifl9 12�• I
ee rovltledhrby5ectlon3700a1lheLeborCatle.lorthapetlormancaolt brklorwhlchlhle �' /�
permitlslaeuatl. )�� � � / (p $BISRIIC �
❑I�eve entl wlll melnteln Workefe Compensetlon Ineurence.ee repulretl by Se<tlon 3700 0l ��y �
ihe Le6or CoOe,lo�the pedormence ol the work�or wM1ich t�la permll la lasuetl.My Worker's / � ..� '„
Compeneetlon Ine1urence cerr er end PoI y num6er ere: TOtBI L��/1 V
cen�er �7�/f poncy No.��6'F� PERMIT AUTHORIZATION DATE
CERTIFICATE OF E%EMPTION FPOM WOqKERS'
COMPENSATION INSUflANCE N.C.p �
(TNe eectlon neatl not be com0letetl II ihe permit le lor one huntlretl tlollere($100)or IeeeJ ���� � � � p
I certl�y thet In Ihe perlormence ol the work lor whlch thle permit le leauetl,I ehell nat employ •L��
a�Y Pe�eo�m e�y ma��,�sa a,ro ce�oma a�eia=��o me wo�kare�comPeneauo��wa oi ceu. All roofs shall be inspected prior to any roo mg material being
ro��ie. installed. Ii a roof is installed without first obtaining an
oaie Applicent inspecTion,t agree to remove all new materials for inspection.
NOTICE TO APPUCANT; If,etlar meklnp Ihis Certlficete ol Exemptlon,you ahould becoma q licant understands and will com p
aub�ect lo t�e Workera'Compensetlon provl6lone af the Lebor Code,you muet lorthwlth comply PP� ply with all non OI(1�
wlih euch provislone or t�ls peimlt 6hell be tlaemeE ravoketl. SOUfCO f0911�2tIOf1S. . '
• Icertlfythetlhevereatlihlaeppllcetlonantletetetheltheebovelniormatlonlecorcect.lepree
tacomplywlthallclryanCcountyorClnenceeentletetelewereletlnpto6ulltlingconetmctlon,entl Allroofcoveringstobeclass orbetter.
�eraEy eulhatlze repreeentativas ol thb city m anror u0on t�e ebova�menllonetl pmparly br In-
apactlon purpoaee.
(We)eprea to eave,InEemnlly nnE kaep hermleee t�e Ciry of Cuper�ino egelnet IIe0111t1ea, .
�uE menta,coata end ezpaneea which mey In eny wey uccrue egalnat seltl Clry in coneapuence
o�tRe e�enune o�m�e Permu. SIGNATURE OF APPLICANT DATE
- �• PAE•INSPECTION: � PLY,WOOD: � � 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