Loading...
R 4959 APPLICATION FOR CITY of cuPERTINo NUMBER R- 4959 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR ' 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS A N r RESIDENTIAL COMMERCIAL OTHER OWNER'S - HAZARDOUS FIRE AREA r YES ❑ If yes—I understand that a Class A NAME roof assembly is required. NO Initial I.C.B.O.fl ADDRESS- Z Z 3 / C'/0/ ;n aV9.�cz- EXISTING ROOF COVERING - PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S /�. • — (_�JL.��"�'•�" TO BE REMOVED TO BE RETAINED NAME ADDRESS TYPE OF ROOF COVERING CITY.a ZIP `/S_ EXISTING PHONE �_ 2 -VTO-22 BUILT-UP ROOF ❑ LICENSE NUMBER ASPHALT SHINGLES El LICENSED CONTRACTORS DECLARATION hereby affirm that I am Ilcensetl under provisions of Chapter a(commencing with Section WOOD SHAKES 700 0)of Division 3 of the Business and Professions Code,and my license Is In full force and effect' WOOD SHINGLES License Class Lic.Number Dale Contractor OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that 1 am exempt from the Contractor's se Law for the following reason. (Sec.7031.5,Business and Prolesslona Code: Any pMj ply which requires a permit to construct,alter,Improve,demolish,or rep air any strudf1' tilts Issuance,also requires the BUILT-UP ROOF El for such permit to file a signs tl state rrppan'tt th e C ad pursuant to the provisions ' of the Contractor's License Lew(Chapter 9 cbmmen n i ction 7000)of Division 3 of the -` Business and Professions Code)or thau,4 Is exam an and the basis far the alleged ASPHALT SHINGLES ❑ examptlon.Any vloletlonoSectlon 7 bye ep Ic or a permit subjects the applicant to e civil penelry of not morn then Ilvs dred it ).): ❑I,as owner of the property, wl h wages as their sole compensation,will do WOOD SHAKES the work,and the structure is not ered for sale(Sec.7044,Business and Pmfes- aloneCode:TheContractor'sLlcens 'does not apply to anownerofproperty who builds or WOOD SHINGLES ❑ Improves thereon,and who does such work himself or through his own employees,provided that such Improvements are not Intended or offered for sale.ll,however,the building or Improvement Is sold within one year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) El build or Improve for purpose of sale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of property who builds or Improves thereon,and who contracts for such projects with a contraclogs)licensed pursuant to the Contractors License Lew, PROVIDE MPGR.INSTALLATION SPECS. ❑1 em rapt and Se ,B 8 P.C.for this reason err--/ - Date APPLICATION DATE VALUATION PERMIT F r RK / COMPENSATION DECLARATION I hereby eHirm under penelry 'perjury one of the following declaration: +" n ❑I have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, V q y BuildIn as provided for by Section 3700 of the Labor Code,for the performance of the work for which this els,` i permit is Issued. CC ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of c//}. ©& Seismic the Labor Coda,for the performance of the work far which this permit Is issued.My Workers (/� Total Compensation Insurance terrier and Policy number are: 1 Carrier Policy No. PERMIT,AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.p (This section need not be completed If the permit Is for one hundred dollars(8100)or less.) I certify that in the performance of the work for which this permit Is issued,I shall not employ any person In any manner so as to become Subject to the Workers'Compensation Laws of Cali- All roofs shallbe inspected prior to any indioling mbterial being fornia, installed. if a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. NOTICE APPLIANT: should subject to theoWorrkeres'Compefnsation provisionafter makinis ofertthelcate Labor Code,you of mustuforthwithbecome comply Applicant understands and will comply with all non point with such provisions or this permit shallibe deemed revoked. source regulations. I certify that I have read this application and state that the above Information Is correct.I agree to comply with all city and county ordinances and erste laws relating to building construction,and All ro verings becl SS"L' batt hereby authorize representatives of this city to enter upon the above-mentioned property for In. / spection purposes. (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, judgments,oats entl expenses which may In any way accrue against said City in consequence SlqL of the granting of this permit. SIGNA UR IC T) DATE PRE-INSPECTION: PLYWOOD: IN-PROGR (NSP. 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 nppirF rnpv