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