R 5906APPLICATION FOR
REROOF PERMIT
�o?6 f6 Bea n 04,
OWNER'S (` `�'
NAME -C/�r�ye,, J�ck4eir (Tu
CITY OF CUPERTINO
INSPECTION DIVISION
(408)777-3228
PHONE f 734?- 32S-
CONTRACT�`!�
NAME
CITYRESS BZP y.17.1 -a of,, _ P0F. __e
�so3
PHONE �7
NIUMBER 'O/ 5 -3
hereby affirm that I am licensed under provisions of Chapter B (commencing with Section
7000) of Division 3 of the Business and Professions Code, and my license Is In full force and
effect. -3 9 52975-X3
License CleenLid. Number I/ow /Y qui 00 ;t
Dote VV Contractor
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the tollowing 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 S (commencing with Section 7000) of Dlvlslun 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 five hundred do liars ($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. If, however, the building or Improvement
is soId 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 Lew does not
apply to an owner of property who builds or improves thereon, and who contracts for such projects
with a contractor(a) licensed pursuant to the Contractor's License Law.
❑ 1 am exempt under Sec. ,B & P. C. for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
ereby affirm under penalty of perjury one of the following declaration:
I have end will maintain a Certificate of Consent to sell -(neuro for Worker's Compensation,
e ovlded for by Section 3700 of the Labor Code, for the performance of the work for which this
Permit
Is issued,
❑ 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
Compensation Ingurenycrp censer and PoI y number are:
Carrier AJC `•e �V/ Policy No. /M�)2/29
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.i]
(This section need not be completed if the permit Is for one hundred dollars ($100) or lees.)
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 Workers' Compensation Laws of Cali.
fornia.
Date Applicant
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
with such provisions or this permit shall be deemed revoked.
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
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. -
save, Indemnify and keep harmless the City of Cupertino against liabilities,
and expenses which may in any way accrue against said City In consequence
this permit.
NUMB'ERR- 5906
PERMIT
WITHIN
RESIDENTIAL ' COMMERCIAL - OTHER
HAZARDOUS FIRE AREA
YES ❑ If yes - I understand that a Cless A
roof assembly is required.
NO ❑ Initial I.C.B.O. N
EXISTING ROO�FF COVERING T
NUMBER OF EXISTING COVERINGS
TO BE REMOVED -1 TO BE RETAINED
TYPE OF ROOF COVERING
EXISTING
BUILT-UP ROOF ❑ 7/58
ASPHALT SHINGLES ❑
WOOD SHAKES
WOOD SHINGLES ❑
OTHER (SPECIFY) ❑
Ie�l���
BUILT-UP ROOF PAID ❑
ASPHALT SHINGLES MR
WOOD SHAKES JUN g 9
WOOD SHINGL€9Y CJt VUrcr 11
OTHER (SPECIFY) ❑
PROVIDE I.C.B.O. REPORT NO. U L %7d
PROVIDE MFGR. INSTALLATION SPECS,
APPLICATION DATE( VALUATION I PERMIT FEE
61 Building 07.0
yr 5-f 6d-). Seismic 7o
TotalQ
PERMIT AUTHORIZATION DATE
O
installed. If 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 roof covert s to be class "C" or better..
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