Loading...
R 5045 (2) PERMIT R_ 5045 APPLICATION FOR CITY OF CUPERTINO NUMBER R- 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 //////) © ✓ RE✓ /✓ ' �"//i ,+.2 ESIDENTIAL COMMERCIAL OTHER O NER'S HAZARDOUS FIRE AREA YES E] If yes—I understand that a Class A NAME roof assembly is required. NO ❑ Initial I.C.B.O.# ADDRESS S t' Q EXISTING ROOF COVERING PHONE / �/ NUMBER OF EXISTING COVERINGS CONTRA TO NAME _ 1. �1 Q v / TO BE nMCVED TO BE RETAINED ADDRESSF RI CITY a ZIP— TIN _ PHONE /O �� 2 BUILT-UP ROOF ❑ CENSE NUMBER Q© [ (D �% 7 ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION hereby affirm that I em Business under Professions of Chapter 8(commenting with Section WOOD SHAKES ❑ \TJ// 7000)of Division 3 of the Business end Prplesalons Cotla,and my license Is In lull force and eons License WOOD SHINGLES , License Clesa Llc.Number Dale - Contractor 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 construct,alter,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF El 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 Dlvlslon 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).1: ❑l,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 Contractors 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.II,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) El build or improve for purpose of sale.). ❑I,as owner of the property,em 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 contractor(s)licensed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS. ❑I em exempt under Sec. ,B a P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I 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, ! BUlldln se provided for by Section 3700 0l the Labor Code,for the performance of the work for which this /vj^ g permit is have and. `Xl b S(�( 7 Seismic ❑ have entl wool the performance Workers f the work for Insurance,as required by Section 3700'of s the Labor Code,for the performance of the work lar which this permit Is Issued.My Worker's B Compensation Insurance carder and Policy number are: Total L-.7?, 9 Carrier PolicyN PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION WORKER COMPENSATION ATIONI ANCE N.C.❑ (This section need not be complete he it is for on untlred tl fere($100)or less.) Oyu• certify that In the P.O.rmance of we for which this ermit' Ie ad shall not employ any person ny manner so as to ome door to the rker ' a an Ion L of Call. All roof.^•shall b pected pri o an rcofingmaterial being f°`nia. installed. a roof is installed wilt t first obtaining an Date gca gree to remove all new m terials for inspection. NOTICE-O APPLICAN : If,after making this Cerullo of Exe peon,you should become subject to the Workers'Compensation provisions of the Labor Cod ,you must forthwith comply erstands and will o ly with all non point with such provisions or this permit shal0be deemed revoked. tions. I certify that l have read this application and state that the abo information is correct.l agreeto comply with ell city entl county ordl nancesend elate laws rale g to building constructionand ngs to be o Bitter. hereby authorize representatives of this city to enter upon the ove-mentioned property for in. spection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities, judgments,costa end expenses which may In any way accrue against Sold City In consequence of the granting of this permit. OF APPLICANT If DATE PRE-INSPECTION: PLYWOOD: IN-PROGRES - 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 -