Loading...
R 5933 PERMIT R_ APPLICATION FOR CITY OF CUPERTINO NUMBER 5 9 3 3 INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR BUILDING ADDRESS. 180 DAYS FROM LAST CALLED INSPECTION. • �ID RESIDENTIAL COMMERCIAL OTHER OWNERS In� /� HAZARDOUS FIRE AREA NAME—LMMONIb OF CUPERMO VES ❑ If assembly mbly sregtl'huts Class A /1 NOeo Initial I.C.B.O.N ADDRESS 10115 EXISTING ROOF COVERING PHONE O 396- 9&0& NUMBER OF EXISTING COVERINGS I CONTRACTOR'S /1 NAME LOS 1 yA ROOFSIJL TO BE REMOVED I TO BE RETAINED •� ADDRESSTYPE OF ROOF COVERING �-�-. -r' CITY B ZIP�71 SMITH AVE., st"s BIOS£. EXISTING PHONE (408) 358 —t2-13 BUILT-UP ROOF ❑ LICENSE ❑ NUMBER ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION hereby affirm that I am licensed under provisions of Chapter S(commencing with Section WOOD SHAKES pq A 1 7000)of Division 3 of the Buusinessss f and Professions Code,and my license Is In lull force and r" ID anaeL p WOOD SHINGLES ❑ License Class C31Gp Lie.Number LICISMIe Dote_DIP 04 98 Contractor L1 5 CA705 ROOFTNI. OTHER(SPECIfPPJ Cp��aVO� OWNER-BUILDER DECLARATION CITY U1- I hereby affirm that I em exempt from the Contractors License Law for the following reason. PROPOSED UU1-art I jlYt/ (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 g(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 e civil penalty of not more than five hundred dollars($500).): WOOD SHAKES the as owner of the property,or my employees with wages as their sole compensation,will do the work,and the structure Is not intended or offered for sale(See.7044,Business and Prolas- atone Cotle:The Contractors License Lew does not apply to an owner of property who bands or WOOD SHINGLES El thereon,and who does such work himself or through his own employees,provided that such Improvements are not intended or offered for sale.It,however,the building or improvement - Issoldwithinoneyearolcompletlon,the owner-builder will have the buean of proving that he did OTHER(SPECIFY) ❑ not build or Improve for purpose of sale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(See.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of property who builds or Improves thereon,and who contracts for such projects with a contmctogs)licensed pursuant to the Contractors License Law, PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt untler Sec. ,B$P.C.for this reason OwnerDate WORKER'S COMPENSATION DECLARAATIOTIO N APPLICATION DATE VALUATION PERMIT FE I hereby affirm under penalty of perjury one of the fallowing declaration: ❑1 have and will maintain a Certificate of Consent to sell-insure for Workers Compensation, Building as provided for by Section 3700 of the Labor Code,for the performance of the work for which this - /� / permit Is Issued DU7- q _nQ ,q(A l Oo Seisf7[C./� ❑1 have and will maithe performance Worker's Compensation the work for which ce,this pe requiredsu d.My Worker's's T�7 -I U "I "`CCCJJJ ,the Lobar Code,for the performance of the work for which this permit Is Issued.My Worker's Compensr�at�io•n Insurance carrier and Polley number are: r Total CarrierA F23=14114 132oTECTIW Policy No. M 0.5 61 95-0 0 PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C.❑ (This section need not be completed If the permit le for one hundred dollars($100)or less.) 1 certify that In the performance of the work for which this permit is Issued shell not employ any person In any manner so as to become subject to the Workers'Compensation Laws of Call. .All roofs shall a inspected prior to Shy roofing material being Ionia, installed. If a roof is installed without first obtaining an Data Oln 'Or/-R$ Applicant aA4" /1.tA/AL 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'Compensation provisions of the Labor Code,you must forthwith comply Applicant understands and will comply with all non paint with such provisions or this permit shalQbe deemed revoked. Source regulations. I certify that I have read this application and stele that the above Information is correct.I agree to comply with all city and county ordinances and state Tawe 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. - spectlon purposes. (We)agree to save,indemnity and keep harmless the City of Cupertino against liabilities, _98 judgments,coats and expanses which may In any way accrue against said City In consequence of the granting of this permit. 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY "