B-2018-1964 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-2018-1964
19147 COZETTE LN CUPERTINO, CA 95014-3538 (375 0.7 020) R E ROOFING AND
CONSTRUCTION INC
SAN JOSE, CA 95124
OWNER'S NAME: DATE ISSUED: 11/16/2018
OWNER'S PHONE: PHONE NO: (408) 626-9320
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B, C39 Lic. #727599
Contractor R E ROOFING AND CONSTRUCTION INC Date 09/30/2020 X BLDG — ELECT — PLUMB
MECH X RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing
with Section 7000) of Division 3-of the Business & Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
RE-ROOF; TEAR-OFF; INSTALL 1/2" OSB; INSTALL COMP
I hereby affirm under penalty of perjury one of the following two declarations: SHINGLES - (8 SQ)
1. I have and will maintain a certificate 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 permit is issued.
2, I have and will maintain. Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. Sq. Ft Floor Area: Valuation: $6000.00
APPLICANT CERTIFICATION
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 APN Number: Occupancy Type: .
and state laws relating to building construction, and hereby authorize 375 07 020
representatives of this city to enter upon the. above mentioned property for
inspection purposes. (We) agree to save indemnify and keep harmless the
City of Cupertino against liabilities, judgments, costs, and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
Cit
.. "+may ab rue against said City in consequence of the granting of this permit. WITHIN 180 DAY
Addition Ily, the applicant understands and will comply with all non-point SOF PERMIT ISSUANCE OR
source
.at0__11/16/2018 Issued by: Jasmine Archbold
` - Date: 11/16/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All r fs shall be inspected prior to any roofing material being installed. If a roof is
installed wit , it first obtaining an inspection,1. I, as owner of the property, or my employees with wages as their sole " g p , I agree to remove all new materials for
Zcompensation, will do the work, and the structure is not intended or offere, for
-��"" ''-
I hereby affirm under penalty of perjury.one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1, I have and will maintain a Certificate 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 permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code, for the performance of the work for which this California Health & Safety Code, Sections 25505, 25533, and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued, I Health &.Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as'to become subject to the
air contp.minants as,defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California, If, after making this certificate of
will rn'aintam complia ee yriit the Cupertino Municipal Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the the Health & .af .t-•µ arde;S,ec 'ons 25505, 25533,.a.nd 2 534.
Labor Code, I must forthwith comply with such provisions or this permit shall
be deemed revoked, O er or /
,f
APPLICANT CERTIFICATION Dat 11/16/2018
I certify that I have read this application and state that the above information is
correct.
O.ILL+"�NDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction, and hereby authorize representatives of this city of work's for which this permit is issued (Sec. 3097, Civ C.)
to enter upon the above mentioned property for inspection purposes. (We) agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments, costs, and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally, the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code, Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 11/16/2018 Professional