Loading...
99120012 of�— PERMI APPLICATION FOR CITY OF CUPERTINO NUMB 410 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 6 ©L.L Q e W QD J ( RESIDENTIAL COMMERCIAL OTHER OWNER'S �+� understand HAZARDOUS FIRE AREA lXJ f ia'c w a o� � l/) r YES ❑ II yes s I undo is req that a Class A NAME I roof assembly is required. NO ❑ Initial- I.C.B.O.# ADDRESS �L.�Jtt.cJo01� EXISTING ROOF COVERING PHONE IS 6 NUMBER OF EXISTING COVERINGS CONTRACTOR'S D NAME C.ILAAZ(L RoC., �I C.^���S(tWsQ TO BE REMOVED TO BE RETAINED ADDRESS K`�f c [� S J - SI Z TYPE OF ROOF COVERING CITY&ZIP KA�+7 EXISTING PHONE C J L� � BUILT-UP ROOFLICENSE , NUMBER ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license Is in full force and effect. G-3'[G�Orp4Q WOOD SHINGLES License Class Lic.Number'` Dam ��3 [� Contractor r RctA� t(t OTHER(SPECT OWNERBUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractor's License Law for the following reason. U (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to DE 999 construct.all er,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 Contractor's License Law(Chapter 9(commencing with Section 7000)of Division 3 of the Business entl Professions Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHING ES ❑ exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to r� a civil penalty of not more than five hundred dollars($500).): WOOD SHAKES B" I,as owner of the properly,or my employees with wages as their sole compensation,will do the work,and the structure is not intended or offered for sale(Sec.7044,Business and Profes. sions Cotle:The Contractor's License Law does not apply to an owner of property 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.If,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) ❑ not 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 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 contestants)licensed pursuant to the Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sec. ,B&P.C.for this reason Owner Dale APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION q I hereby affirm under penalty of perjury one of the following declaration: –/ ❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, IZ Z' 1 y Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of '7-i • )15 q SBISfn IC the Labor Code,for the performance of the work for which this permit is issued.My Worker's (� I V l Compensation Insurance carrier and Policy number are: - Total Carrier FRLWmL��04/� PolicyNo.W 64r3�-dJ PERMIT AUTHORIZATION DATE CERTIFICATE OF EXE PTION FROM WORKERS' COMPENSATION INSURANCE 100)o (This section need not be completed if the permit is fora undyed tlollors($100)or less.) I certify that in the performance of the work for which th' ermit is issued,I shall not employ any person in any manner so as to become subject to the orkera'cempenaauen Laws of Cali. All roots shall be inspected prior to any roofing material being forma, installed. If a roof is installed without first obtaining an Date /Z� Applicant inspection,I agree to remove all new materials for inspection. NOTICE T APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understa and will comply with all non OIDt subject to the Workers'Compensation provisions of the Labor Cade,you must forthwith comply PP P y P with such provisions or this permit shall be deemed invoked, SOUfC. regulabOn I certify that I have read this application and state that the above information iscorrect.I agree to comply with all city and county ordinances and state laws relating to building conshuctfon,and OTURE Coverings Obec sS" rbetter. hereby authorize representatives of this city to enter upon the above-mentioned property for in. sp(Wet purposes. (We)agree is save,indemnity and keep harmless the City of Cupertino against liabilities, judgments,casts and expenses which may In any way accrue against said City in consequence OF APPLICANT DATE 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE'COPY