R-5623L
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBERR_ 5623
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT START
WITHIN 100 DAYS OF PERMIT ISSUANCE
180 DAYS FROM LAST CALLED INSPECTIC
COMMERCIAL OTHER
NAME
Mill YES ❑ If yes – I understand that a Class A
root assembly is required.
NO Spe Initial_
ADDRESS Q MP 0 -IS (� O O I)Aa� EXISTING ROOF CI
ITY & SS
ZI
CITY a ZIP
1.-05 6 -a -hos ,
ACNE 40t -�3 2„
LICENSE � �O
NUMBER `i Y i/I
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Cape, and my license eis I full force and
.ff
License
3�
Licse Class 1_.�L— Up.. Number �/Z
Date — _ / Contractor
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors 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
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Seaton 7000) of Division 3 of the
Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged
exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than eve hundred dollars ($500),):
I, 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 (Sec. 7044, Business and Profes-
slons Code: The Contractor's License Law does not apply to an owner of property who builds or
Improves 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
Is sold within one year of completion, the owner -builder will have the burden of proving that he did
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 Contractor's License Law does not
apply to an owner of property who builds or Improves thereon, and who contracts for such projects
with a contractors) licensed pursuant to the Contractor's License Law.
❑ I am exempt under Sec. ,B 8 P. C. for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have and will maintain a Certiflcale of Consent to self -insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this
p ml Is Issued.
have and will maintain Worker's Compensation Insurance, as required by Section 3700 0l
the abor C e, lot the padormance of the work for which this permit Is Issued. My Worker's
'Co panne Insu me ler and Policy number are: ��
Carrier Policy No IV
CERTIFICATE OF EXEMPTION FROM WO KERS'
COMPENSATION INSURANCE N.C7
(This section need not be completed II the permit Is for one hundred dollars ($100) or lass.)
I certify that In the performance of the work for which this permit Is Issued, I shall not employ
any person In any manner so as to become subject to the WorkereCompensation Laws of Cell-
fornia.
Date Applicant
NOTICE TO APPLICANT: If. alter making this Certificate of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
with such provisions or this permit shafts deemed revoked.
I certify that I have react 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
hereby authorize representatives of this city to enter upon the above-mentloned property for In.
spection purposes.
(We) agree to save, indemnify and keep harmtess the City of Cupertino against Ilabliales,
judgments, costs and expanses which may In any way accrue against said City In consequence
I.C.B.O. s
NUMBER OF EXISTING COVERINGS
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
EXISTING
BUILT-UP ROOF )
ASPHALT SHINGLES ❑
WOOD SHAKES
WOOD SHINGLES ❑
OTHER (SPECIFY) ❑
PROPOSED
BUILT-UP ROOF
❑
ASPHALTSHINGLES
WOOD SHAKES
❑
WOOD SHINGLES
❑
OTHER (SPECIFY) ❑
PROVIDE I.C.B.O. REPORT NO.
f I/
PROVIDE MFGR. INSTALLATION SPECS.
(APPLICATION DATEI VALUATION I PERMIT FEE I
Buildiggw_
A I Seismi``ciib
�D G Total
._PERMIT AUTHORIZATION DATE
installed. It a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
source regulations.
All root coverings to be class "C" or better.
SI TURE 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
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-'In'put Permit
Number:
PERMIT#:
R5623
ARCHITECT: F
VALUATION:
7200
APN:
35618041
UCENSE #:
ISSDATE:
7/2/97
SITUS STREET:
COLUMBO
SUBDATE: 7/2/5
PLCHKDONE:
SITUS NO#:
21762
TYPE:
RSR
LATE L:
AVE,CT,STAD:V
BLDGODEODE:
N,S,E.W:
DESCRIPTION: REROOF
ENGDEPT:
NO#:
PIANDEPT:
CITY:
CU
CMA:
Z
95011
CATE00EQ:
CATEGORY:
CTRCMA
LOT#:
D
DATEDUE:
SANDIST:
ID:
Commercial
HLTHDEPT:
O'WNER:
OWNER
MAKI ROBERTWAND SU
21762 COLUMBUS AV
CA'sq#It#.
CE-sq#It#:
STR TDTAL
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ADDRESS:
CN,sp#II#
INSPHOID:
TY,STREETZIP:
PHONE:
CUPERTINO CA 95
4089960179
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CONTRACTOR:FIEKq#ftt
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LIC#:
195316495346
RUSUSagllll#:
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