Loading...
R 45520 • NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY PERMITR_ 455 R- 27 APPLICATION FOR CITY OF CUPERTINO NUMBER PERMIT INSPECTION DIVISION PERMIT EXPIRATION (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 1\\ ZI &0 �Q&z, RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA ( - 1 YES ❑ "yes- I understand that a Class A NAME < I roof assembly is required. NO Initial I.C.B.O. If. ZI an 'r EXISTING ROOF COVERING ADDRESS CI ' PHONE -2S Z— FJ NUMBER OF EXISTING COVERINGS (0V1'2- TO BE REMOVED TO BE RETAINED CONTRACTOR'S['I 1 / - NAME 1I)MA U ' r,tyL ] W ADDRESS(� � li O x ' � �1 G �- q 0 _ TYPE OF ROOF COVERING CITY B ZIP i� 1� 0 f I� EXISTING y'OO-5J�-13Z� PHONE ❑ BUILT-UP ROOFLICENSE (0 C_ C 3 NUMBER ASPHALT SHINGLES ❑ e WOOD SHAKES J LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provlslone of Chapter B (commencing with Sects 7000) of Division 3 of the Business and Professions Code, and my license Is In lull force d 1133 WOOD SHINGLES ❑ V License Clees �(o License Lie. Number �0_ YS OTHER (SPECIFY) ❑ Dale Conor lraCt PROPOSED A OWNER-the Conn DECLARATIONrsLicense hereby affirm that I am exempt from the Law for the B reason. (Sec. 7031.5, e: Any or roue and Professions Code: Any city or county which requires a permit tocons P r, Improve Improve, h, or repair ementrthat e, taste Issuance, the �I'(jh prior also requires applicant to filedemosigned statement applicant for such permit to Isle a signed statement that he Is licensed pursuant to the provlslone BUILT-UP ROOF t ❑ of the Contractor's License Law (Chapter 0 (commencing with Section 7000) of Dlvlelon 3 0l the Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500).): n�w 6p ❑ I, as owner of the property, or my employees with wages as their sole compensation, will do WOOD SHAKES �1 ,NI may, the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Profes- slons Code: The Contractor's License Low does not apply to an owner of property who builds or v C 1 Clas Improves thereon, and who does such work himself or through his own employees, provided that WOOD SHINGLES ❑ S 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.). , ❑ Las 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 contractors) licensed pursuant to the Contractor's License Law. E]I am exempt under Sec. ,B a P. C. for this reason PROVIDE MFGR. INSTALLATION SPECS. Owner Dale APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLAflATION. I hereby affirm under penalty of perjury one of the following declaration: ❑ I have and will maintain a Ceftillcate of Consent to sell -insure for Workers Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this / ./� I �s� BUIIdI"B�A�`ts permit le Issued. vIL `O �J I / Seismic have and will maintain Workers Compensation Insurance, as required by Section 3700 0l ins Labor Cotle, for the performance of the work for which this permit Is Issued. My Worker's Compensation Insurance carrier and Policy number are:^^ Total SWC rs- 3 PERMIT AUTHORIZATION DATE Carrier -1p Policy No. dI CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.p/ (This section need not be completed It the permit Is for one hundred dollars ($100) or lase.) tct I certify that In the performance of the work for which this permit Is Issued, I snail nal emotoy any In become All roofs shall be inspected prior to any roofing material being person any manner so as to subject to the Workers' Compensation Laws of Cali- fornia. installed. If a roof is installed without first obtaining an Dale Applicant inspection, I agree to remove all new materials for inspection. NOTICE To APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply Applicant understands and will comply with all non point with such provisions or this permit shell be deemed revoked, source regulations. I certify that I have read this application and state that the above Information Is correct.) agree to comply with all city and county ordinances and state laws totaling to building construction, and All roof O fR lCbec�las "C" or hereby authorize representatives of this city to enter upon the above-mentlonod property for in- /beft. spection purposes. (We) agree to save, Indemnity and keep harmless the City of Cupertino against liabilities, -16judgments. -§IGNATtJRE costs and expenses which may in any way accrue against said City In consequence OFAPPLICANT DATE at the granting olthis 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