Loading...
R 6165 RMIT 4NUMBER R- 6165 APPLICATION FOR CITY OF CUPERTINo REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN DAYS PERMIT ISSUANCE OR WI DAYSS FROM LAST CALLED INSPECTION, BUILDING ADDRESS �• �� ��� �``H .RESIDENTIAL_COMMERCIAL OTHER OWNER'S - HAZARDOUS FIRE AREA /I�1y�� I. - YES ❑ Byes-I understand that a Class A NAMEJ_/ � VL � � roof assemdy Is required. NO ❑ InNal I.C.B.O.# ADDRESS__ S CLW tee. EXISTING ROOF COVERING PHONE k's— NUMBER OF EXISTING COVERINGS / CONTRACCjOR' NAME r.40S &11V(J�ADDRESS / 749876? F7Q�6+'I"'�/41�A .'� TO BE REMOVED X TO BE RETAINED cTY s ZIP 2�/LL�AOX� /. l�� Clams & TYPE OF ROOF COVERING PHONE-CyQ O / IJ� . / 3J EXISTING ROOF ❑ LICENSE NUMBER ASPHALT SHINGLES Q' LICENSED CONTRACTORS DECLARATION J'C I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES ❑ 7000)of Division 3 of the Business and Professions Code,and my license to In lull force and effect. WOOD SHINGLES ❑ License Claes Lic,Number W1 3 Date contmcto OTHER(SPECIFY) ❑ OWNER BUILDER DECLARATION UPROPOSED 1 hereby affirm in that I am exempt from the e: Any ore License Lew for the following a reason. (Sec. construct, ct, It Business and demolish, Profeor repair Code: Any city or county which re.also sa requires permit to applicnt.elter,Improve.to file signed statemenny trthat here,priorlofts Issuance,to the BUILT-UP ROOF ❑ of the nt for such permit to file a signed statement nci g it licensed Pursuant to the n 3 of the of the ss an Pro License Professions Law(Chapter S(commencing with Section 7000)of Division 3 0l the Business end violation of Cotle)or thet he Is exempt therefrom and the beefs for the applicant to ASPHALT SHINGLES ❑ exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to e dull penalty of not more than five bundredy employees dollayees with wage WOOD SHAKES [ ❑Lae owner of the tune Is or to ded oyeee with wages as their axle compensation,will s. the work,and the structure Is not Intended or offered for sale(Sec.7044,property and Profes- sionCode:The,an who License Law does not apply toanowner ofpropertywhoided or WO©0-S"GLES ❑ Improves thereon,and who tloes such work himself or .11,how his own employees,provided the such Improvements are not Intentletl or offered for eels.II,however,the building or 1 n n ill Is sold within one year of completion,the owner-builder will he"the burden of provin I he did O .ER(�FECIFY) ❑ not build or Improve for purpose of sale.). I� t ❑I,as owner of the property•am exclusively contracting with licensed contractors t truct 111, the project(Sec.7044,Business and Professions Code:The Contractor's License La not 1 r.P DE I.0 B.O.REPORT NO. apply to an owner of property who builds or improves thereon,and who contracts for su rjeC1VOV 2 U ILfI� with a contractor(s)licensed pursuant to the Contractor's License Law. 1V PROVIDELNI GR.INSTALLATION SPECS. ❑ em exempt under Sec. ,B 8 P.C.for I eason Owner Data L 0N-DA E VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION gy I hereby aBlrm under penalty of perjury one of the following declaration: -37. ❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, Building as provided for by Section 3700 of the Labor Cotle,for the performance of the work for which this permit is Issued. Seismic I have and will maintain Worker's Compensatlon Insurance,as required by Section 3700 of Me Labor Cotle,for the performance o he work for which this permit Is Issued.My Workers n Q Compens n Insurance ntprrler and P y n mbar aC LD Total card- "c1l . No..�a./ 1GA L PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.CC (This section need not ba Completed If the permit is for one hundred dollars($100)or less.) I certify that In the performance of the work for which this permit Is Issued.I shall not empjoy any person in any manner so as to become subject to the Workers'Compensation Laws of Ce1L All roofs shall be inspected prior to any roofing material 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 TO APPLICANT: If,attar making this Certificate of Exemption,you should become Applicant understands and will I with all non slot subject to the Workers'Compensation provisions of the Labor Code.you must forthwith comply PP comply Y P with such provisions or this permit shalC be deemed revoked, Source regulations. I certify that l have read this application and state that the above Information is correctl agree ,/� to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"6Or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. spejudJW-n purposes. (We)agree to save,peIndemnityes and keep harmless way the City ai Cupertino against llabllen e, ltdgmente,coals and expenses which may m any way accrue against mltl City in SIGNATUREO P ANT DATE of the pmnting of ihle palma, ' 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