R 5908 J
PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 5908
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
_ - WITHIN 180 DAYS OF PERMIT ISSUANCE OR
( 180 DAYS FROM LAST CALLED INSPECTION.
fill BUILDING ADDRESS
/tp 9SOIV RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
//-- [' YES ❑ It yes—I understand that a Class A
G
NAME e0okx e_ cl roof assembly is required.
NO Initial I.C.B.O.N
ADDRESS 5//� EXISTING ROOF COVERING
PHONE Q R 6 O 00 - NUMBER OF EXISTING COVERINGS -
CONTRACTOR'S - _
ReAJae s s k,Llc e�- P1Qr!/✓G l�['�x. �C . TO BE REMOVED TO BE RETAINED
NAME
ADDRESS / (.UCO[-� ✓ S� 9,,5/2 S TYPE OF ROOF COVERING
CITY&ZIP L—
p D EXISTING
PHONE Z/08 — yny0 (/�', 0 69 BUILT-UP ROOF ❑
NUMBER SS7 �� " ��ee
ALT SHINGLESA G D ❑
LICENSED CONTRACTORS DECLARATION
In
affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAK 1 0 pA(S
7000)of Division 3 of the Business and Professions Coda,and my license le In full force and 4
effect. Xtoze
�� 5 S9 ]�.3 .3 14 99 OD SHIAIf&K ❑
Ucenee Class 3 Lic.Number /! VUr C1'1l uVV
(c�0�R9 /�Zn.0 a/SS.4aCe Raotr�/ OTHER(SPECIFY) ❑ _______S d�
Data— Contractor
OWNER-BUILDER DECLARATION PROPOSED
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,after,Improve,demolish,or repair eny structure, ortoIt laealso
requires
quiresthe BUILT-UP ROOF
applicant for suchpermitto file esinstatement
taamthat he Is licensed pursuani totheprovisions
rovl e El foy'le�
of the Contractor's License Law(Chapter a(commencln with Section 7000)of Division 3 of the ` f
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 live hundred dollars($500).1:
01,as owner of the property,or my employees with wages as their sola 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 Contractor's License Law does not apply to an owner of property who builds 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 safe.If,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
bulld 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 Contractoea License Law does not PROVIDE I.C.B.O.REPORT NO. U1 'x-90 CL.fF.2
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 Contractor's License Law. PROVIDE MFGR.INSTALLATION SPECS.
El am exempt under Sec. ,e a P.C.for this reason
Owner Date
WORKER'S COMPENSATON DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, G Building `0
as provided for by Section 3700 o1 the Labor Code,for the performance of the work for which this 70
rmb I.aaed. / 7, 3•y3-- Seismic t .�u
have end will maintain Worker's Compensation Insurance,as required by Section 3700 of
ub,Kahor Code,for the performance of the work for which this permit��aa Issued.My Works �s
ompeneation Insurance carrier and Polley number ere: Fr Jr'P/Q�— //h//yQ Total 2�
Carrier -S 7-,+,-e- /-UAW Polley No. QI'y—� 503 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)
f certify that In the performance of the work for which this permit Is Issued,I.hall not employ '
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,alter making this Certificate of Exemption,you should become Applicant understands and will I with all non point
subject to the Workera'Compensation provisions of the Labor Code,you must forthwith comply PP comply Y P
with such provisions or this permit shall be deemed revoked. sourgolegulations. -
I cerfity 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 etatelaws relating to building Construction,and Al DO COVerin s atter.
hereby authorize representatives of this City to enter upon the above-mentioned property for in.
spection
(We)agrpoaae. /�a 9
(We)agree s save, sees Indemnify and keep nay ay the City a against
Cupertino against liabilities, (O
judgments,costa and expenses which may In any way accrue against veld City Inconsequence IGNATURE OF APPLICANT DATE
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS: K 1I
INSP. DATE INSP. DATE INSP.—DATE
TEAR OFF INSPECTION: A BATTENS: FINAL: fC
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY ��