Loading...
R 5144• OFFICE COVV PERMIT R- 5144 APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 1e0 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS R��jj /� / SA I— CM RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA 12 A YES ❑ If yes — I understand that a Class A NAME roof assembly is required. NO I-of I.C.B.O. q 06 L I u ANLL bi44 9W 7_ ADDRESS EXISTING ROOF COVERING / PHONE 4 Is"- NUMBER OF EXISTING COVERINGS TO BE REMOVED TO BE RETAINED CONTRACTOI NAME /Tl r �_f gC)©6 f'44 (7—�-- ADDRESS eP X 963` (- 63(- 444 4 TYPE OF ROOF COVERING CITY & ZIP EXISTING y �I('�' PHONE ( BUILT-UP ROOF LICENSE NUMBER �4 ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby allirm that I am licensed under provisions of Chapter 8 (commencing with Secllon WOOD SHAKES ❑ 7000) of Division 3 of the Business and Professions Code, and my license is In lull force and effect.((( `i �_ 3 4 WOOD SHINGLES ❑ Licennse Cleve Llc. Number Date q-11'*'S6 Can a, OTHER (SPECIFY) ❑ OWNER•BUILDERD CLARATION I hereby affirm that I em exempt from the Contractor's License Law for the following reason. PROPOSED (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, 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 a (commencing with Section 7000) of Division 3 of 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 live hundred dollars ($500).): C] I, as owner of the property, or my employees with wages as their sole compensation, will do WOOD SHAKES ❑ the work, and the structure la not Intended or offered for sale (Sec. 7044, Business and Profes. alone Code: The Contractor's License Law does not apply to an owner of properly who builds or Improves thereon, and who does such work himself or through his own employees, provided that WOOD SHINGLES ❑ such Improvements are not Intended or offered far safe. If, however, the building or Improvement Is sold within one year of completion, the owner -builder will have the bu rden of proving that he dirt not build or Improve for purpose of sale.). OTHER (SPECIFY) ❑ ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Prolossions Code: The Contractors License Law does not PROVIDE I.C.B.O. REPORT NO. apply to an owner of property who bunds or Improves thereon, and who contracts for such projects, with a contractor(s) Ilcensetl pursuant to the Contractor's License Law. ❑ I am exempt under Sec. ,B 8 P. C. for this reason PROVIDE MFGR. INSTALLATION SPECS. Owner Data WORKER'S COMPENSATION DECLARATION APPLICATION DATEI VALUATION PERMIT FEE 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, as provided for by Section 3700 of the Labor Code, for the performance of the for this 4ja / G G / — / 7 00 V Buildin �07 g� work which per luaveand' -� �p CSQd /.4-0 have and will maithe pert Worker's Compensation the work th or Code, for the performance of the work for which this permit le issued. My Worker's or Insurance, as required is u Section 3700's Seismic Campers on Insurance cerriaran Policynuryber are: D� ��� Carrier O Y Total AUTHORIZATION DATE a. CERTIFICATE OF M FROM EXEMPTION FROM WORKERS' �• �� EN COMPENSATION INSURANCE 100) o (Tele section need not completed If the permit is for one dollars ($100) or less.) th¢ r of the them the performance of the work for which this permit le Issued, shell not employ permit Is I All roofs sh be inspected prior to any roofing material being person any parson In any manner so as to become subject to the era Compensation Laws, ar cat). f°`°Ia.. )' (,r installed. f a roof is installed without first obtaining an Date (1—�`' Applicant ft•J Q�/l-L-t?i1.C. inspection, I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If, after making this Certiffcate 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 PP p y p with such provisions or this permit shall be deemed revoked. source regulations. I certify that I have read this application and state that the above information Is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and All roof c verings to be cls C. por better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. sppurposes. (We) ag (We) agreeato neve, indemnity and keep harmless the Clry Cupertino against liabilities, judgments, coats and expenses which may In any way accrue against said City In consequence of the granting of this Parma. 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COVV