R-6275 PERMIT
APPLICATION FOR clTv of cuPERTINo
NUMBER R- 6275
'INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 77-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
- WITHIN 180 DAYS OF PERMIT ISSUANCE OR
\� 160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
0Sr76 029-A.,6 . /4 v,_ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ N yes—I unAeTsland that a Class A -
NAME ,�;7 roof essemt*y is required.
NO El mf
I.C.B.O.A
ADDRESS /r'S1 7L2 EXISTING ROOF COVERING '
PHONE. - NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S -
L.0/�4�o -lt_ f2 moo- i tic 'TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP
PHONE--;7;>;7 if33/ BUILT-UP ROOF ❑
CENSE
NUMBER G ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm Met I am Iicerul under prov Morns of Chapter B(commencing with Section WOOD SHAKES
700o)of Dhislon 3 of Ne Busne re and Prolaesions Code,and my license Is In full force end '
effect.
WOOD SHINGLES
Uconse Class C_39 uc.Number - S
Date `7 �4Sr Conn ctor OTHER(SPECIFY) �� Ile
OWNER-BUILDER 6ECTIOhl PROPOSED
I hereby affirm Mat I am exempt from the Coramctore License Law for Me following reason. i G. -
(Sm.7031.5,Business and Professions Code: Any city or county which requires a permit to O
construct.alter.Improve,demolish,or repair any structure,prior to Ile Issuance,also rmulreo the BUILT-UP ROOF Q -
appiram for such permit to file a signed statement that he is licensed pursuant to the provlelons
of the Contractors License Law(Chapter B(commer cinp with Section 7000)of DhIsicn 3 of the -
• Buenas and Professors,Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ❑ "
exemption.Any vbla0on of Section 7031.5 by any sell ler a permit wblects Me applicant to
e dog Penalty of net more than Mre hundred dollars( ).):
❑I,as owner of Me property,or my employees wages an their tole compensation,will do WOOD SHAKES ❑
the work,and the structure is not intended offer a(Sec.7046,Business and Profen
skms Cade:The Contractors License to an owner of property who bulkts or WOOD SHINGLES ❑
Improves Menson,and who does ouch w or ough his own employees,prmridatl Mat
each Improvements are not Intended or offered r sole It,hoer,the building or Improvement
It eoldwahln one year of completion,Me -0Ildor will have the burden of praWng that he A'd OTHER(SPECIFY) ❑
not bulla or Improve ler Purpose of sale.).
- ❑I,eeownerofmaprmerty,ammclusI Iycmtrectlrq MMlic mdccrfisdoretoconstrud )S
the project(Seo.7044,Suelns"and Prof{salons Code:The Contractors Umnse Lew does not PROVIDE I.C.B.O. REPORT NO. 0,4 � ✓
appy to an owner of property who bullae or Improve,thereon,and wnd contracts ler ouch projects
with a ccrllraatm(e)Iken,ed pursuant to me Cmtredor's License taw. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.ler this roosen
Owner Date APPLICATION DATE - VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penelry of perjury we of me following emanation:
I hese and will maintain a Certificate of Consent to sell-Insure for workers Compensation, Building7r 00
as p Ikkd for try Sectkn 370D o1 the Lobar Code,ler the performance M the work ler which Mie �s fin/.
permit 1 is h wend will maintain Worker's Compensation Insurance,as required by Becton 3700 of I V � � Seismic
70
the Labor Cade,for Me performance of the work for which Ile permit Is issued.My Workers
Compensation Insurance render and Policy number are: Q sal I �` yl7
Carrier�'s-a� =✓��/1 Poky No =%� PERM UTI-ORI 10 DATE
- CERTIRCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C4D T 2 ✓
(This section need not be completed If the permit le for one hundred dollars($100)or least JQ e- 70A �`r
I cortity Mel In the performance of the work ler which this permit i,issued,I shell not employ
any person In any manner w as to become subject to Me Workers'Co Lawn of can- All roofs sh ll be inspected prior to an fing material being
1°r"'e' , / installed. f By Cot is installed withou first obtaining an
Date Applicant ^{ F inspection, rials for inspection.
subject NOTICE M Work APPLICANT:Com Iles^me�stonie of the Ldb°roCode,you you should become Applicant understands and will comply with all non point
pe p you moat ronhwlth comply
MM such proNalons or this permit ehelCbe deemed revoketl. � SOUfCe fagUlatIORS.
I con"at I have read Mie application and elate Met Me above Inlonnabon Is correct.I agree
to comply Ml all dry and county ordinances and state laws relating to bullding construction,and All roof Coverings to be class"C"Or better
hereby authorize repreeentatFass of Ile dry to enter upon the above-mendened property for In.
epmbon purposes. —
(We)agree M solve,.indemnity and keep hormleee Me cry of Cuportlrw agonal Ilab111fies, —�" /��,�Judgments,wets and expenses winch may In any way accrue against sold Gry In consequence OF APPLICANT ATE
of the granting of Mie permit. SIGNATURE-
•' 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