R-6537 PERMff
APPLICATION FOR CITY of cuPERTINo NUMBER R" 653
7
REROOF PERMIT INSPECTION DIVISION PERM, EXPIRATION
(408)777-3228. PERMIT EXPIRES IF WORK IS NOT STARTED
_ - - WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM UST CALLED INSPECTION.
BUILDING ADDRESS ��
a �3 - RESIDENTIAL=K COMMERCIAL OTHER
OWNER'S 1 f - HAZARDOUS FIRE AREA
�ONM0' �•)�y y VES ❑ ryes-Irmbly is requested.
Initial
ChasA
NAME III VVV LLL CLU• l 1.11LA.f roof assembly is refilmed. i
NO ❑ Initial I.C.B.O.�
a a 9a 3 ��� �y EXISTING ROOF COVE
ADDRESS /��/ A
PHONE V-� 4 I NUMBER OF EXISTING COVERIN S
CONTRACTOR'
TO BE REMOVED TO BE RETAINED
NAME
ADDRESSn PE
OF ROOF CMR
CIN&ZIP i J • J
rAr p L"halm
PHONE1 ✓ �� BUILT-UP ROOF ❑
LICENSE El
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that,am Ilceneed under pr61slor s of Chapter B(commencing with Section WOOD SHAKES
7000)of Divlslon 3 of the Buchass and Professions Code,and my Ilcense Is In full force and
effect. WOOD SHINGLES G
License Cleve �3 9 Dc.Number n . .
Date ;q11Conn ar - OTHER(SPECIZY) t. b
OVyNER-BUILDER DECLARATION r'
I hereby affirm that,am exempt from the Contractors Ucense Lar for the following reason. PROPOSED II MAY 1 11999
(Sec.7031.5, Buehe.and Profession Code: Any city or county which requires a permit to u
cortaVrxB,after,iimprooe,demolish,or repair any structure,prkr to its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Pa,kensed pursuant to the provlelone fJ
of the Contractors Lkane Lew Chapter B(commencinp wM Section 70(0)of Dlviekn 3 of the [3Y
Business end Profeeelan Codes or that he b exempt Iherelrom and Me basis for the al"ad ASPHALT SHINGL
exemption.Any violation of SeNon 7031.5 by any applicant W e permit wblects the applbant M
a cMl penalty W not more then five hundred dollar,fif 0 ).):
01.ae owner of Me property,or my employees with"gee as their sob compensation,w,,,do WOOD SHAKES E
the work,and Ma structure Is not Intended or offered for We(Sec.7044,Business and Prof ss-
sions Coda: The Contracture License Law does not apply to an owner of property who bulks or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided Met
El
such Improaements are not Intended or offered for sale.If,however,Me building or Improvement
Is sold within one year of completion,Me awner-Wilder will have Me burden of proving that he did OTHER(SPECIFY)
not Wild or,mirnme for purpwe of We.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to constructh G1
flys project(Sec.7044,Business ark Professors Code:The Contractors License Law does not PROVIDE I.C.B.O. REPORT NO. O-
apply to an owner of property who builds or Impmvee thereon,and who connote for such projects
with a contractor(e)licensed pursuant to Me Cantrectore License Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 8 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the foecwing declaration:
❑1 have ala will maintain a CertHbete N Cuneent to self-Insure for wonders Compensation. Building
as pros for by Section 3700 of Me Labor Code,for the performance of the work for whlch this �/"�
P
lesoed. J J
=will will meinlaln Workers Congeneetlon Insurance,as required by Section 3700 0l Seismic 1,G�CL
ih r Co for the performanc of the rk lar which ml permit is lasued.My Workers
ngensel, ren rartl lky n Wer are: n_ Total I 60
Caner Policy No.—Afslynma PERMIT AUTHORIZATION DATE
- CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑ ' ! r
(Thea section rued net nd completed H the permit is for ono hundred sued.I($1 DO)or Im Y
certify In t n the perbrmas to of the work for which MIs permit fe m"ns shall not em by
any person In any manner so ee to become subject to the Workers Compeneetlon Lowe of „-, All roofs shall be inspected prior to any roofing material being
tome. - 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 makirig this Certificate of Exemption,you Mould become Applicant understands and will comply with all non int
subject to Me Worker,'Compermetbn provisio m of the Labor Code,you must forthwith comply pP P Y point
with such provlelon,or this peml MelObe deemed revoked, source regulahons-
I cortity that I have reed Mie application ark state that the above Informetlon Is correct.I agree
to comply with all city ala county ordinances and state Iowa relating to buelding constructlon,end All r OVerin s t be6 or better.
hereby authorize representatives of MIs city to enter upon the above-mentioned property for In-
spechon purposes.
(We)agree to save,Indemnify ala keep harmless Ma City of CupeNrw against IlebllHeee, -
judgmenla,coots and oesenses which may In anlnt y way accrue bil said City In consequence $IG RE OFA - E
of the granting of Mie permit.
PRE-INSPECTION: PLYWOOD: 1 =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