Loading...
R 5103 APPLICATION FOR CITY OF CUPERTINO NUMBER R— 510 3 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR . ` 1 S DAYS FROM LAST CALLED INSPECTION, BUILDING ADDRESS 3sRESIDENTIAL COMMERCIAL OTHER OWNER'S 1— HAZARDOUS FIRE AREA 'f�TT�' n A .�T: VES ❑ It yes—I assembly is req that a Gass A NAME 1J_ LJ \\ ]]] ffl "V,V/\\1 CC.�� ��' 111�� ��1 roof assembly is required. NO ❑ Initial I.C.B.O.a ADOREss EXISTING ROOF COVERING hOVERING PHONE - NUMBER OF EXISTING COVERINGS CONTRAQZORS TO BE REMOVED ' TO BE RETAINED NAME v� .ADDRESS (� TYPE OF ROOF COVERING y CITY&ZIP v a PHONE - U A c, Q,/1p J� 3 BUILT-UP ROOF ❑ LICENSE NUMBER U ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provisions at Chapter a(commencing with Section WOOD SHAKES ❑ 7000)of Divislon 3 of the Business and Professions e,and my license is in full 1 n c ❑ affect. /^ fC'�/ WOOD SHINGLES License Clae Lic.Number 1 OTHER(SPECIFY) ❑ Date Carl D o! Nom BUILDER DECLA cense PROPOSED hereby a Bu that em exempt from the e: Any or county Law for the following permit . (Sec.7031.5,Business and Professions Cotle: Any city or county which requires a permit to ) r construct,alter.Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF ❑ applicant for such permit to fila a signed statement that he Is licensed pursuant to the provisions �� of the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the Business and Professions Code)Or that he Is exempt therefrom and the locale for the alleged ASPHALT SHINGLES exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to , I" . 99 a civil penalty of not more than live hundred dollars($500).): 'Jy- U E]1,as owner of the property,or my employees with wages as their sole compensation,will do O DSHAKES l.c,!-❑ the work,and the structure is not intended or offered for sale(Sec.7044,Business and Proles- alone Code:The Contractor's License Law does not apply to an owner of property who builds or� W SHINGLES Improves thereon,and who does such work himself or through his own employees,provided their ❑ such Improvements are not Intended or offered for sale.If,however,the building or improvement Is sold within one year of comptetlon,the owner-builder will have the burden of proving that he did �OT (SPECIFY) ❑ not build or Improve for purpose of cele.). I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Prolasslons Code:The Contractor's License Law does not 0 E C.B.O.REPORT NO. apply to an owner of property who builds or Improves thereon,and who contracts for such projects with a contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR. INSTALLATION SPECS. ❑I am exempt under Sec. ,B&P.C.for this reason Owner Data WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby and under Penney of perjury one of the following declaration: refoWo ❑Ih If for Sectiill on tain a3700 of the ate bol Consent the performance at Compensation,thn, r � I BUIIdI v s a:rmltI Is forby Section 3700 of the Labor Code,for the partarmenceof the work for which this I f permit Is have and. Seis ❑ have and will the performance Worker's Compensation Insurance,hicthis as required Is by Section 3700 of Ctheo Labor Code,for the padaor d of the work for which lhla permit is leaned.My Worker's .� Compo n aura ca cerrlar tl Policy nu bar ere��( , 'I� � Total Cards ncy o. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.0 /r (This section need not be completed If the permit Is for one hundred dollars($100)or least //O I certify that in the performance of the work for which this permit is Issued,I shell not employ any person in any manner so safe become subject loth W rkem'Comparselion Laws of Collo All roof!:Sh a inspected prior to any roof g material being fornl installed. If a roof is installed without first obtaining an Date -�� Applicant inspection,I agree to remove all new materials for inspection. NOT Io TO or Ia'Com If,after making this of eLab of Exemption,you should seamy Applicant understands and will comply with all non point withhied to he Work e'Compensation provisions of the Labor Code,you must forthwith comply PP p y p with cuch provisions or this permit shation deemed revoked. SOUfCe regulations. to I reply with all have red thirty ordinances and d state to laws above Ito buildtioning construction,and hereby authorize rep and tabes ordinances a enter upon the ve-ma tions property f end All roof coverings be cl s"C"or better./� hereby authorize representetivee Of this dry to eater upon the ebovementionetl property for In. `r( epecllOn purposes. (We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, jutlgments,costs and expenses which may In any way accrue against said City In consequence of the granting of this permit. §GNATUREO A PLIC DAT 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 COPV APPLICATION FOR CITY OF CUPERTINO NUMBER R— 510 3 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR . ` 1 S DAYS FROM LAST CALLED INSPECTION, BUILDING ADDRESS 3sRESIDENTIAL COMMERCIAL OTHER OWNER'S 1— HAZARDOUS FIRE AREA 'f�TT�' n A .�T: VES ❑ It yes—I assembly is req that a Gass A NAME 1J_ LJ \\ ]]] ffl "V,V/\\1 CC.�� ��' 111�� ��1 roof assembly is required. NO ❑ Initial I.C.B.O.a ADOREss EXISTING ROOF COVERING hOVERING PHONE - NUMBER OF EXISTING COVERINGS CONTRAQZORS TO BE REMOVED ' TO BE RETAINED NAME v� .ADDRESS (� TYPE OF ROOF COVERING y CITY&ZIP v a PHONE - U A c, Q,/1p J� 3 BUILT-UP ROOF ❑ LICENSE NUMBER U ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provisions at Chapter a(commencing with Section WOOD SHAKES ❑ 7000)of Divislon 3 of the Business and Professions e,and my license is in full 1 n c ❑ affect. /^ fC'�/ WOOD SHINGLES License Clae Lic.Number 1 OTHER(SPECIFY) ❑ Date Carl D o! Nom BUILDER DECLA cense PROPOSED hereby a Bu that em exempt from the e: Any or county Law for the following permit . (Sec.7031.5,Business and Professions Cotle: Any city or county which requires a permit to ) r construct,alter.Improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF ❑ applicant for such permit to fila a signed statement that he Is licensed pursuant to the provisions �� of the Contractor's License Law(Chapter g(commencing with Section 7000)of Division 3 of the Business and Professions Code)Or that he Is exempt therefrom and the locale for the alleged ASPHALT SHINGLES exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to , I" . 99 a civil penalty of not more than live hundred dollars($500).): 'Jy- U E]1,as owner of the property,or my employees with wages as their sole compensation,will do O DSHAKES l.c,!-❑ the work,and the structure is not intended or offered for sale(Sec.7044,Business and Proles- alone Code:The Contractor's License Law does not apply to an owner of property who builds or� W SHINGLES Improves thereon,and who does such work himself or through his own employees,provided their ❑ such Improvements are not Intended or offered for sale.If,however,the building or improvement Is sold within one year of comptetlon,the owner-builder will have the burden of proving that he did �OT (SPECIFY) ❑ not build or Improve for purpose of cele.). I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Prolasslons Code:The Contractor's License Law does not 0 E C.B.O.REPORT NO. apply to an owner of property who builds or Improves thereon,and who contracts for such projects with a contractors)licensed pursuant to the Contractor's License Lew. PROVIDE MFGR. INSTALLATION SPECS. ❑I am exempt under Sec. ,B&P.C.for this reason Owner Data WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby and under Penney of perjury one of the following declaration: refoWo ❑Ih If for Sectiill on tain a3700 of the ate bol Consent the performance at Compensation,thn, r � I BUIIdI v s a:rmltI Is forby Section 3700 of the Labor Code,for the partarmenceof the work for which this I f permit Is have and. Seis ❑ have and will the performance Worker's Compensation Insurance,hicthis as required Is by Section 3700 of Ctheo Labor Code,for the padaor d of the work for which lhla permit is leaned.My Worker's .� Compo n aura ca cerrlar tl Policy nu bar ere��( , 'I� � Total Cards ncy o. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.0 /r (This section need not be completed If the permit Is for one hundred dollars($100)or least //O I certify that in the performance of the work for which this permit is Issued,I shell not employ any person in any manner so safe become subject loth W rkem'Comparselion Laws of Collo All roof!:Sh a inspected prior to any roof g material being fornl installed. If a roof is installed without first obtaining an Date -�� Applicant inspection,I agree to remove all new materials for inspection. NOT Io TO or Ia'Com If,after making this of eLab of Exemption,you should seamy Applicant understands and will comply with all non point withhied to he Work e'Compensation provisions of the Labor Code,you must forthwith comply PP p y p with cuch provisions or this permit shation deemed revoked. SOUfCe regulations. to I reply with all have red thirty ordinances and d state to laws above Ito buildtioning construction,and hereby authorize rep and tabes ordinances a enter upon the ve-ma tions property f end All roof coverings be cl s"C"or better./� hereby authorize representetivee Of this dry to eater upon the ebovementionetl property for In. `r( epecllOn purposes. (We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, jutlgments,costs and expenses which may In any way accrue against said City In consequence of the granting of this permit. §GNATUREO A PLIC DAT 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 COPV