R-6435 PER
APPLICATION FOR - CITY OF cuPERTINo
NUMBIER R� 6.435 ,
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
_ WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
�I `,��v� ^ . , YES ❑ H ye.seind �and tthat red. CWss A
NAME (� /.�7V rotes is tared.
NO ❑. Initial I.C.B.0:;1
ADDRESS S EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
NAME I�—�� /A/ S-SA>r/Lb TO BE REMOVED TO BE RETAINED
ADDRESS ` h - TYPE OF ROOF COVERING
CITY a zIP 4,P B/ Z
EXISTING
PHONE J /ir 6�0 9 7 BUILT-UP ROOF ❑
LICENSE
NUMBER 7Y ASPHALT SHINGLES ❑
LICENSED ON TRACTORS DECLARATION
I hereby affirm that I em licensed under provisions of Chapter B(commenting with Secuon WOOD SHAKES
7000)of Division 3 of the Business and Professions Cade,and my license Is In full force and
effect.
7 3 WOOD SHINGLES
Lkerwe Cleve�. `l� Lb.Number_ / /
Date �—�� coniredor OTHER(SPECIFY) D
OWNER-BUILDER DECLARATION PROPOSED 7EB019991 hereby affirm that I em exempt from Me Contractor's License Lew for the following reason.(Sec.7031.5,Business end Professors Code: Any city or county which requires a permit tcorwrwY,after,Improve,demolleh,or repair any structure,prior to Ile asuance,also requlrea BUILT-UP ROOF
applicant for such permit to flle a signed statement that he Is licensed pursuant to the poovislo
of the ContractoYs Ucense Law(Chapter a(commenting with Section 7000)of Dlvlslon 3 01
Business and Professions Code)or Mel he Is exempt therefrom and the basis for the all SPHALT SHINGLE By
exemption.Any vfo ffien of Section 7031.5 by any applicant for a permit subjects Me epolean to '
e evil porosity d rod more than rwe hundred before($500).):
❑1,as owner of the property or my emp"s with wages as their ads compensation,will SHAKES ❑
the work,ark the structure Is not Intended or offered for sale(Sec.7044,Bushxes aril Prefee-
ebne Code: The Contrsctoes Ucense Lew does not apply to an owner of property who builds 0r
Improves therein,end who does such work himself or through hie own employees,provided Met O LES ❑
such Improvements are cwt Intended or offered for sale.If,however,the Wllomr;or Improvement
not build
f s Me ownerWlltlar will have the burden of pradrg that he dm T R ISP
❑
notbulltlor Irtneyefor lebr al saleJ. �^
❑1,as owner of Me property,em exclusively contrectin9 with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PRO E LC.B.O.REPORT NO.
apply to an owner a property who Gilds or Impress therein,and who contracm for such projects
with a contractor(s)licensed pursuant to the Contractor's License Lew.
7) P. PROVIDE MFGR.INSTALLATION SPECS.
1 em exempt under Sec. ,B E C.for this reason
Owmer Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm unser penalty of perjuryone of the following declaration:
❑1 have and will malnte rr a CerlMcato of Consent to sai insure for Workers Conpensellon, Building
as provided for by Section 3700 of the Labor Cade,for the performance of the work for which this _^/ C ``',T
permit le Issued. - v �� I A (.� Seismic
❑1 Neve ark MII rnalnMln Wo r6 pe n Insurance,as required try Section 3700 d /
Me Lobar Cade,for the parlor nce Ihs r which this permit U lsul My Workers
Corrpensetlm In- ce ar Iky rare: Total
Cerner '� PolkyNo, �'LC�i 7 9 PER AUTHORIZATION DATE
CERTIFICATE O EXEMPTION FROM WORKERS'
COMPE SATION INSURANCE N.C[]
(Title section need not be Completed If Ma permit Is for One hundred dollars($1 DO)Or less.)
1 04"that In the pedormarroce of the wore for which MIs permit Is Iasi ad,I shell not empty
any person In any manner so as to become subject to the Workers'Compensation Laws 01 CeIF At I roofs M be inspected prior to any roofing mate nal bei rfg
forms. installed. If a root is installed without first obtaining an
Date Appkeant inspection,I agree to remove all new materials for Inspection.
NOTICE TO APPUCANT: ll,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to Me Workers'Cempimsalon proNskxu a the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shelrbe deemed revoked. sOUr gulations.
I badly that I have read this application and state that the above Inbnretlon Is correct I agree
to comply wfth all dry and county ordinances and state laws relating to building construed.,and root verings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above,mentIoned properly for In.
Reaction purposes. .
(We)agree to save.Indemnify and keep hermiess the City of Cupertinoege Inst liabilities, -
judhgme�seals l of ark is a permit
which may In any way accrue agetrwt said Clty In corwequerxx AT OF PPLICANT 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