Loading...
R 4850 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- 4850 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN DAYS PERMIT ISSUANCE OR / WI DAYSS FROM LAST CALLED INSPECTION, BUILDING ADDRESS 76.3 J S�RaDI✓ H/LL L/ +� �.�� RESIDENTIAL !!!!� COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA YES El If yes—I understand that a Class A NAME Mrd' S- I-ltao',.Iroof assembly is required. NO Initial I.C.B.O.N ADDRESS ✓ EXISTING ROOF COVERING PHONE Z S—2 — O NUMBER OF EXISTING COVERINGS CONTRACTOR'S NAME u .�.v.�eY G TO BE REMOVED TO BE RETAINED ADDRESS fl� COVERING CITY&ZIP- _S�c2Ll 40�Ql0 EXISTING PHONE BUILT-UP ROOF - ❑ LICENSE 6'6 6 ASPHALT SHINGLES NUMBER ❑ LICENSED CONTRACTORS DECLARATION C7 I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES !/ 7000)of Division 3 of the Business and Professions Code,.and my license Is In full force and effect. License Class � Lie.Number6 6 WOOD SHINGLES Date CP— 7— contractor L�� OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to 71�I construct,alter,Improve,demolish,or repalrany structure,prior to Its issuance,also requires the BUILT-UP ROOF l( UG "2 Zq99 6 applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions of the Contractor's License Lew(Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professlons,Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES "r- L exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to e civil penalty of not more than rive hundred dollars($500).): q v ❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑ the work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profes- sions Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES Improves thereon,and who does such work himself or through his own employees,provided that ❑ 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.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec,7044,Business and Professions Code:The Contractor's License Lew 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 contractor(s)licensed pursuant to the Contractor's License Law, PROVIDE MFGR.INSTALLATION SPECS. E]I am exempt under Sec. ,B&P.C.for this reason Owner oats WORKER'S COMPENSATION DECLARATION APPLICATION DATEI VALUATION PERMIT FEF. I hereby affirm under penalty of perjury one of the following declaration: - ❑Ihaveantl willSection 3700 of the ate bor Consent theperInsure forWorker's Compensation, D�1�� �� y `��,,,^ Bui din aermiti Is Mr by Section 3700 of the Labor Code,for the performance at the work for which this C/' i 7 j Jr permit is Issued. ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of 00Seismic the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's Compensation insurance carrier and Policy number are: .q Total Carrier 0*7,0 -'f� Policy No. '9/619 / PERMIT AUT TE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE hi (This section need not be completed If the permit Is for one hundred dollars($100)or lees.) I certify that In the performance al 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'Compensetlon Laws of Cell. All roots S al inspected prior to any roofi m terial bei g rorne. installed. f a roof is installed without first obtaining an Data '� -�'- pplicant Cti--L _ inspectionj agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,alter making this Certificate of Exemption,ifli should become Applicant understands and will comply subject to the Workers'Compensetlon provisions of the Labor Code,you must forthwith comply pP ply with all non point 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 coverings to be class"C"or better. hereby authorize representatives of this city to enter upon the above-mentioned property for In. spection purposes. (We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities, A -1?— 6 judgments,costs and expenses which,may In any way accrue against said City In consequence of the granting of this permit. SIGNATURE OF APPLICA 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 J