Loading...
R-5439• OFFICE COPY PERMIT 5439 APPLICATION FOR CITY OF CUPERTINO NUMBERR_ INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (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 p /� ID3 0O —C eei AUK l t RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA I�/� and that nd that YES ❑ It yes (understa, Class NAME % t 1 - I / roof assembly is s NO ❑ Initial I.C.B.O.# �j' y� lo 3 O ©� 'I ��- EXISTING ROOF COVERING ADDRESS D I I / S- NUMBER OF EXISTING COVERINGS 1 PHONE CONTRACTOR'S f� v� _/ j NAME 1� �, , I t A N ( ri �,ft n k TO BE REMOVED TO BE RETAINED - ,/� ADDRESS .tel �� `z I �I�C �D TYPE OF ROOF COVERING CITY & ZIP ��CC EXISTING HA(T�wA9-0 CA PHONE 33 t i , BUILT-UP ROOF CENSE NUMBER L/3(63 ASPHALTSHINGLES ❑ LICENSED CONTRACTOR' DECLARATION hereby affirm that em licensed ender provisions of Chapter B (commencing with Section WOOD SHAKES ❑ ]000) of Division 3 0l the Business and Professions Code, and my license Is In full lone and effect' WOOD SHINGLES ❑ License Class Lic, Number OTHER (SPECIFY) ❑ Date Contractor OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. PROPOSED (Sec. 7031 5, Business and Professions Cotle: Any city or county which requires a permit to construct, eller, 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 Lew (Chapter B (commencing with Section 7000) of Division 3 of the Business and Professions Coda) 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 e civil penalty of not more than five hundred dollars ($501 WOOD 17 I, as owner of the property, or my employees with wages as their sole compensation, will do .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.). I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code: The Contractors License Law doe. net 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. 711 am exempt under Sec. ,B & P. C. for this reason Owner -' Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declaration: I have and will maintain a Certificate of Consent to self -Insure for Worker's Compensation, Building as provided for by Section 3700 of the Labor Code, for the performance of the work for which this Permit 1. Issued. ( 0-11-97 Seismic ❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Worker's Total Compensation Insurance carrier and Policy number ere: Carrier Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' T �_ �1 _ D V`n r"t COMPENSATION INSURANCE N.C.O (This section need not be completed If the permit Is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit Is Issued. I shell not employ any person In any manner so as to become subject to the Workers' Compensation Laws of Cell- All roofr. shall be inspected prior to any roofing material being fornia, 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: It, after making this Certificate of Exemption, you should become Applicant understands and will comply with all non point PP P Y P subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shalQbe 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- .pectlon purposes. (We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities, judgments, coats and expenses which may In any way accrue against said City In consequence SIGNATURE OF APPLICANT DATE of the granting of this permit. PRE -INSPECTION: PLYWOOD: IN -PROGRESS: INSP. DATE INSP. DATE INSP. DATE TEAR OFF INSPECTION: BATTENS: FINAL: TQ INSP. DATE INSP.-DATE INSP. DATE - NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY