The URL can be used to link to this page

R-4615 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R— 4 615 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 RESIDENTIAL —COMMERCIAL OTHER OWNER'S �A HAZARDOUS FIRE AREA ,Q YES C] If yes—I understand that a Class A NAME roof assembly is required NORO LC.B.O, ROOF k ADDRESS EXISTING OF COVERING PHONE NUMBER OF EXISTING COVERINGS - CONTRACTOR'S BE REMOVED TO BE RETAINED NAME ?W ADDRESS �2 l TYPE OF ROOF COVERING CITY&ZIP c' ' �� '`��l��OQ/� EXISTING PHONE �� "� C / BUILT-UP ROOF ❑ LICENSE NUMBER ASPHALT SHINGLES ❑ LIC SED CONTRACTORS DECLARATION hereby inion that am si licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES ]000)of Division 3 of Business and Professions Code,and my license is In full force and effect. WOOD SHINGLES ❑ License ClasLic.Numbe734r OTHER(SPECIFY) ❑ Date Contractor OWNER-BL ILDERD RATI PROPOSED hereby affirm that em exempt from Iha Contractors Lice a Lew for the following reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to construct,ager,improve,demolish,or repair any structure,prior to Its issuance,also requires the BUILT-UP ROOF ❑ applicant for such permit to file a signed statement that he is licensed pursuant to the provisions • of the ss and tProf License Lew(Chapter a(commencing twithherefrom Section 1000)of Division 3 of the //nn Business and Professions Cotle)or that he Is exempt ant fora and the su basis forhe the alleged SPHALT SHINGLES per. p •C/r exemption.Anyviolationotmoethan ion hundred byany applicant fora permit subjects the applicant to a civil pasty of not more than live hundred tlollars($wage: WOOD SHAKES S ❑� G.� ❑I,as owner dthe structure i not I my tended employeeswithwages as(Sec.their sole compensation,snPrefer.r. the work,and the structure is not Intended or offend for sale n ow er of Business and builds or Bions Code:reo ,Cant recto d License Law deals not apply toanowner of property who buildsor WOOD SHINGLES O improves thereon,end who does such work himself or through his own employees,provided that (� such improvements are not intended or offered for sale.If,however,the building or improvement Is sold within one year completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) GrF ❑ not build or improve for purpose of sale.). y'r/yyYU ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractor's License Law 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 contractor(s)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am 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 following declaration: I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, , J ] Bull as provided for by Section 37a o1 the Labor Code,for the Performance of the work for which this /•1 y �j //}/ ©U permit is issued, ('� ,Nut 000• Seismic ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Cotle,for the edormanc of the wor or which this permit Is issued.My Worker's Total 'Compen/eyk�o•�ry��su- carrier an licy nu er are: ////�. 01 Carrier`••"�• Policy NtN" 151-1�Q�C7 P RMIT AUTHORIZATI DATE CERTIFICAT EMPTION FROM WOflKERS' COMPENSATION INSURANCE N.C.❑ (This section need not be completed if the per for one hunit re tlollars($100)or iess.) 1 cenity that in the need, of the work"7.*wrl Ihis per it is issueq shell not employ any person In an manner o as to became a( to a Wo r cam ensetI Lawe of Call- All roe shall be insp cte nor to any oof g materia ei fornia. installed. If a roof is installed without first obtaining an Date Ly Applicant inspection,I agree to remove all new materials for inspection. NOTIC TO AP LICANT: If,eller making this Certific of Exemption,you should become Applicant understands and will comply with all non point subject to he We ars'Compensation provisions of the r Code,you must forthwith comply PP P Y p with such provisions or this permit shaltbe deemed revoked. sourC ulations. 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 state laws relating to building construction,andAI 0of coverings to be cl or better. 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,costs and expenses which may in any way accrue against said City in consequenceUR APPLICANT AT of the granting of this permit. 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