R-6603 APPLICATION FOR 'CITY of cuPeRrlNo
NUMBIERR- 6603
INSPECTION DIVISION. PERMIT EXPIRATION
REROOF PERMIT
(408) 777-3MPERMITEXPIRES IF WORK IS NOT STARTED
WITHIN
WITHIN FROM
PERMIT ISSUANCE O
180 DAYS
FPAM L4ST CALLED INSPECTION..
BUILDING ADDRESS
/ RESIDENTIAL COMMERCIAL OTHER
OWNER'S F/�//�/� Q �C�I� HAZARDOUS FIRE AREA
!4L' ��'1a e P� lam- �=�T� VES ❑ r of ass8�YMired a Class A
NAME 'S roof s fired.
ADDRESS ` //V� EXISTING ROOF COVERING
PHONE- _ NUMBER OF EXISTING COVERINGS
CONTRAC R' a �
NAM b a—J'- M10 TO BE R ED—TO BE RETAINED
ADrDRESSTYPE OF ROOF COVERING
CITY&ZIP 3 14- -T
PHONE L'Or+ �/ ? �p BUILT- OFLICENSE
-
NUMBER L DV A ❑
LICENSED CONTRACTORS DECLARATION ±OE
� -v
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section H�KES '�I,j ❑
7070)of Division 3 of the Business and Professions Coote,and my Iloense a In lull farce entl - II
eflecl., 3� Ncl 1999 -i ❑
' Lkene�e�Class��,�pO Lk.Number
O lu
Data 7(L z / / Connect« O PECT FYIL ❑
OWNER-BUILDER DECLARATION
1 hereby, ,Business
I em exempt from the Code: Anyfory Uranus Lew for the uires reason.
(Bath 7001.5, rminese am xemptProfesslonsfrom theCAiry city or se L which for requires a permit to
construct,after,Improve,domolleh,or repair any structure,prior to he Issuance,also requires the BUILT-UP ROOF
applicant for such marsh to Isle a aligned statement that he Is Ilcoreed pursuant to me provisions
of the Contractors Lowest Lew(Chapter a(commencling with Section]000)of DNIslon 3 of the
Business and Prof Sodom Code)or that he Is exempt themtrom and the hash for the alleged ASPHALT SHINGLES ❑
exemption.Any violation of Section 7031.8 by arty appikent for a permit subject,the applicant to
e dv11 Penalty of rot more than Mrs hundred dollars($SW).):
❑L se owner of the property,«my employees with wages a,their ads compensation,will do WOOD SHAKES ❑
the work.and Me structure Is not Intended or cheroot for eats(Sec.7044,Bugkreu and Profes.
stands Code: The ContmGore Ucerae Lew ticea not appy,to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself on through his own employees,provided that ❑
such Improvwneme we rot Intended or offered lot sets.If,however,Me Wilding or Improvemen
Is sold within one year of completion,the owner-builds will have the buroen of proving that he dot (SPECIFY)rot hullo or Improve icr purpose of date.). OTHER( "! ❑
❑I,a,owner of tra property,am exclusively contrectlno wIM)icendad contractors to construct
Me project(Sao 7044,Buslneee and Professions Coote:The Conbectoes Lowrie,Law does rat PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who builds,or Improved Meran,and who contracts for such projects
wIM a conrxmn(a) Im eed pursuant to the Contractor's License Lew. PROVIDE MFG R. INSTALLATION SPECS.
C]I am exempt under Sec. ,B 6 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty,of perjury one of Me following declaration:
Fj I have end will malnein a Certificate of consent to self-Insure kx Workers Compensation,' Bulldin
as provWed ter by Section 3700 of the Lothar Cade,for the performance of the work for which tlJa g
permit Is veuetl. / —lq /;•/v. r J mac, O
have and will Me performance
Worker's Compensation Iwhich this
as reculi
Is I su Section orlu of /V� ill/l/,/ (.(�- Tv/V`H•�) SBISn11C
the tor Coote,for Me pedormence of the work fon which hale permit le issued.My Warkere
Compense on nps"u�ra'nce a not Policy number are: Total
Cnrder " ' � t'�'A, Pdky No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEM"ON FROM WORKERS'
COMPENSATION INSURANCE r N.Ca q
(The section need not be completed 0 me permit Is for oro hundred dollars($1 W)«lege.)
I caddy that In the performance of the work for wNch this permit Is Issued,I shell not empsoy
«ry wmn In arty manner a a,to become a tb♦ to oto W«kara'C«npaneatlon Laws of Calk All roofs shall be inspected prior to any roofing material being
romla. 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 Certificate of Exaapdon,you eh culo become Applicant understands and will comply with all non int
subject to the Workers'Compensetlon provisions of Me Labor Code,you must forthwith comply pP P Y PO
with such provisions or this permit ahalObe deemed revoked, source regulations.
I certlty Mat l have reed this appticatlon and state that the above Information 1,cortect l agree
to comply with all city and county ordiummus and state lewd totaling to budding construction,add All rO VenngS Lobe class rbetter.
hereby authorize reprasmadves of Ws city to enter,upon Me above�mendoneo properly for In-
epectlon purposes.
(Wel agree to save,Indmi and keep hanntsse the City of Cupertlro againstuabllNes,
lutl ns,,coats ark expenses which may In any way accrue against oak City n con,equenco
of e��grantinganhispermit. ' IG ATUREOFAPPLICANT 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