Loading...
R 6371 l PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 6371 REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 1130 DAYS OF PERMIT ISSUANCE OR BUILDING ADDRESS 100 DAYS FROM LAST CALLED INSPECTION. ' RESIDENTIAL COMMERCIAL OTHER OWNER'S / / HAZARDOUS FIRE AREA NAME �'�y��1.�'N•Q�� YES ❑ If yea ss�that a Class A y squired. NO ❑ Initial I.C.B.O.W ADDRESS— EXISTING EXISTING ROOF COVERING PHONE r�G' y NUMBER OF EXISTING COVERINGS / CONTRACTOR'S TO BE REMOVED TO BE RETAINED NAME— ADDRESS /O r/ � �� LYPE OF ROOF COVERING CITU&ZIP q9r19� EXISTING PHONE BUILT-UP ROOF ❑ CENSE NUMBER ' ' ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES Q� 7000)of Division 3 of the Business and Professions Code,and my license is In lull force and enact. .-V ;qWOOD SHINGLES El ZZLicense Claes Llc.Number & 77 Date 9-30-00 Contractor �G 450 E" OTHER(SPECIFY) OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. PRO SED (Sec.7031.5,Business and Professions Code: Any city or county which requires a,peardt• l construct,alter.Improve,demolish.or repair any structure,prior to Its issyarweat -W915're'ulrabthe T-UP ROOF ❑ applicant for such permit to file a signed statement that he Is licensed puWW���A44uuuuuaAO[�t to the ppgqrdJislIee�ns of the Contractor's License Lew(Chapter a(commencing with Section 7(p.0).QI Dlvisfn Tone e Business and Professions Code)or that he Is exempt therefrom and the ba s for iiiWe alleged ALT SHINGLES exemption,Any violation of Section 7031.5 by any applicant for a permit s bjec' the eolicent his �p a civil penalty of not more than five hundred dollars($500)): Jp PF•(V`a 1& v ❑ EJ 1,as owner of the property,or my employees with wages ee their sole open she", ill o SHAKES the work,and the structure is net Intended or oderetl for sale(Sec.]044 Inas and Proles- alone Code:The Contractor's License Lew does not apply to an owner of p o arty who builds or WOO SHINGLES ❑ improves thereon,and who does such work himself or through his own em ogees,provltletl Ihet such Improvements are not Intended or offered for Bala.If,however,lite buil ilio P((Improvement Is sold within one year of completion,the owner-builder will have the burden IproJingihytt6 OTHER(SPECIFY) ❑ not bulltl 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 Coda: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 contract&for such projects with a contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS. ❑I am exempt under Sec. ,B&P.C.for this reason Owner Dale WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: ❑I have and will maintain a Certificate of Consent to sell-Insure for Worker's Compensation, BUlldin J as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this . O permit - ./Z-/��� 7/ �G� Seismic 0 Babor entl will the performance Worker's Compensation work fon Insurance,as permit dsu Section3700 orkeof ,the Labor tion I for the performance of The work for winch this permll is issued.My Worker's / 7, Q q Compensation Insurance carrier and Po/lacy number are: � Tote/� '� Carrier&'�/ � dr q,4 Policy No.�7 /04f4—?? PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N,OO (This section need not be completed if the permit Is for one hundred dollars($100)or less.) 1 / rtfOA 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'Compensagun Laws of Cell-• All r ofs shall Nnspected prior to any rooting material being forela' : 'I .�, 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: 11,after making this Certificate of Exemption,you should become subject to the Workers'Componsatlan provisions of the Libor Code,you must forthwith comply Applicant understands and will Comply with all non point with such provisions or this permit shalrbe deemed revoked. • Source regulations. I certify that I have read this application and stele that the above information i&correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and All roof Coverings to be Class 6r better. hereby authorize representatives of this city to anter upon this above-mentioned property for in. spection purposes. (We)agree to save,Indemnity and keep harmless the City of Cupertino against liabilities, judgments.costs and expenses which may In any way accrue against said City In consequence of the granting of this permit, SIGNATURE OF APPLICANT DATE 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 '