Loading...
R 5370 (2) PERMIT 5370 " APPLICATION I © CITY OF CUPERTINO NUMBERR- r INSPECTION DIVISION REROOF PERMIT f 7 (408)777-3228 PERMIT EXPIRESIFWORN SNOT STARTED ( + WITHIN 180 DAYS OF PERMIT ISSUANCE OR r 1B DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS - 7 D 3 ORESIDENTIAL COMMERCIAL OTHER OWNER'S ail HAZARDOUS FIRE AREA VES roof❑ If yes-I understand that a Class A NAME �/tC/t /�.2Z1�'wf( l', assembly is required. 2 /yf ,\q, NO ❑ Initial I.C.B.O.N ADDRESS " ! ` "✓ d'/� d4-;aj&J-;v4 / EXISTING ROOF COVERING PHONE zll e4 NUMBER OF EXISTING COVERINGS CONTRACTOR'S NAME � G- py�✓q TO BE REMOVED / TO BE RETAINED ADDRESS / TYPE OF ROOF COVERING CITY&ZIP D9,!([0'.✓o f.._ " �� EXISTING PHONE J�'U� 1 •BUILT-UP ROOF ❑ LICENSE NUMBER 72 ,1�i - ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provisions of Chapter g(commencing with Section WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license is In lull force and effect. ( License Claes n�- j� Lid.Number A V WOOD SHINGLES ❑ 9�6� .� Date Oo Contractor ,G Aoo! OTHER(SPECIFY) El OWNER-BUILDER DECLARATION ! I hereby affirm that I am exempt from the Contractor's License Law for the lollcwing reason. PROPOSED (Sec.70315,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 provleons of the Contractor's License Law(Chapter B(commencing with Section 7000)of Division 3 of the • Business and Professions Code)or that he le exempt therefrom and the heels 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 1$500).): 01.as owner of the property,or my employees with wages as their sole compensation,will do D WO ❑ the work,and the structure Is 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 property who builds or WOOD IN S Improves thereon,and who does such work himself or through his own employees,provided that Alin ❑ �-y e rpm suchimprovements are not Intended the offered for safe.e,however,ins building oiIgPmt he dId OT'liE4�( PI£6lF,Y) '/�•Ti• �ZG not build ld or I provne e for purpose s the owner-builder will have the burden of proving that he tlld OTME $ sE /rJQ�J7 rrqq not bulltl or Improve for purpo6e o/eels.). y�- ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct J�� the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not y PROVIDE I.C.B.O. ORT NO. apply to an owner of property who bulltls or Improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor.License Law, GR.IN ALLATION SPECS. ❑I am exempt under Sec. ,B&P.C.for this.reason Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of pedury one of the following declaration: ❑1 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 O g [/ permit Is Issued, (/ $elSfl'11C have entl will the performance Worker'rmancee f the work ion Insurance,as required by d.My Worker's of ��, Y to bor Cotle,for the performance of the work lar which this permit Is leeuetl.My Worker's / Compensation Insurance carrier and Policy number are; i//' Total ` Q Carrier � � Gk./, PolmyNo.,7/ 14L 'p^9z PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.❑ - (This section need not be completed If the permit is for one hundred dollars($100)or lase) 53 / / I certify that In the performance of the work for which this permit is Issued,I shell not employ t` any person In any manner so as to become subject to the Worker.'Compensation Laws of Cell. All roofs shall be inspected prior to any roofing material being fornla. - installed. If a roof is installed without first obtaining an Data 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'Compeneetlon provisions of the Labor Code,you must forthwith comply Applicant understands and Will com with all non point with such provisions or this permit shall be doomed revoked. Source regulations. I certify that I have read this application and state that the above Information le correct.Degree to comply with all city and county ordinances and state law.relating to building conabuctlonentl All erin Stob sS"C"or better. hereby authorize representatives of thes city to anter upon the above-mentioned property for In- spection purposes. (We)agree to save,Indemnify and keep harmless the City of Cupertino agalnsl Ilebllltlee, D 7K judgmemts.coat.and expenses which may In any way accrue against said CityIn consequence of the granting of this permit. IGNATURE OF APPLICANT DATE • PR&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 COPY