00060177"
CITY OF CUPERTINO-
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
'
BUILDING ADD111,109 I 'BUBB'RDr
{ WOODS ROOFING
ERMULNO: 000E.01.77
.APPLICATION
OWNER'S NALBVAN BLOMMF_ STEIN.. I OMA-
o' 1020' HICKORY GT'V'
1�1b/gd6/2000
IIONF.
('83.1')63'7-5576`
SANITARY NO. _CONTROL NO.
,
n O O
ARCHITECTIENGINLFR.;
y `
Gr
•3• BUILDING PERMIT INFO
EE
+ •M _
r-,
BLDG " ELECT PLUMB , MECH
2 Z
LICENSED CONTRACTOR'S DECLARATION
Job Description' -
pZ_p
Ili by rf thtl airlicenseduncle Prn .' fCh pt 9(bm ne ang
F�pw
wimb t ]oo) rD' nneBa p rv.,n.ca en,y1 m
'ism
SHAKES ,TO COMPOSITION SHINGLES'
�.MfJwJ
�full l 'daft
L¢ Lie
-
6. C m J
Cl
Dat contractor
�3w�
C�0�
ARCHITECTS DCCLARAlIUN
1 J.t d 'hall be hlcrecrd,
.. "
-
- .. / j',' -
<�
yPl used pt
-
7 C C
W�pO
accrue IP t "un'J
,/7/ t -
°' °� o
w
t "r
OWNER BUILDLk DECLARATION'
I hereby aR n that I n e t d fromt Contractor's L L for the
Carlo A
.q V
,I 10 v ,
•k -
d
Toll g . (S t ]0915 H I Prot .. y city at try
,
p�
which q p n construct, II p demolish, r P any It acorn,
priort t 1 q theFPI' tI pe tt I gn l'moment
Sq. Ft. Floor Area
-
(hath I . npursuant,t thep to fm Co, , e L Law '(Chilton,ode)
(w mveeise Bootge Cade),
lig ric dion,
•
An,nr.
emptteadframon
alleged
.1 that '. exempt th f doh, basis for theIl pule pt AYvioPl on-
and the ba
cofSection-70315byaY PPI''tfraP tsubjectstheablo a rapenalty
ofn t thanfsehundred l lls5o0.
( )
- .AP
-
Occu enc Type
P. Y YP
3��r�cID�103. 00 •
-rY
❑IvnownerolPoor cry. or my employees wim wages as their vole w ,Penstion,•
all dr the work and th-.t t t Waited . IYe d f o (Sao ]Oq4
Business and ProfessionsCode TheC t t I 1 d t apply tont
�q� Ulred Inspections
P
305
of preparty Who bolds or imp a fl cot and bar doe4,r ch work himself
— FRAME o t
olr
lnmugh his awn employees provided lnul such improvements not Intended or
'lding
^ — 'I NSULRT I ON"� -
-
offered ( If. h It b p Id. iM1' t, your of
iotplf m bdd will avec h e fP amgmtn Tato, hand or
-
.307'
- - E01` —' ROOF TEAR OFF
mp forpu,.,a efsale). - ,..
- .-�
"
❑I, asmoorofthe property, ame.clusivel'ycarton �hatwith rcensedantiouchater,
602 — ROOF PLYWOOD ''NAIL
k'
'
construct the t (See. 7044, BLsiness,and Professions Calc:) The Conhucta's'an,,
° s n
_
-
603 —; ROOF BATTENS
Law does not apply m tm owner of a candy won builds improves thin the
and who for aa,n ptvimta with, a ,omrnutorla) licensed pursuant to me
and woo us
'f-`; "ROOF 'I
Liecm
LiCeme Laos. Lr
6Qi4' N-PRQGRESS
0 1 an, eta f
❑ l am e.empt adder sea:. , h at P e nor tn'iu rea,on:
x'.
Owner Fin
WORKERSCOMPF,NSAlION DLCLARAl10N;
Iheachyeffirn de pnllY (Perjury ane of the toll ng aedurl n
.. .
1 I have and x ll n vv u n Cert fsvte of Co,een to elf ns re.fo Waken x
t
'ampensm on, as Provided - for by Season 3700 `of the"Lab Code, for ober-
Edofam tcaof the ,r kf hichthisp 1 ,Bed.
❑II d wril°nanmm Workers Comp i I required by Sectio(
Insurance.
9700 of the Code,our the pInsurancee of the work for Much thispermit is
1
Worker's
ed My Worker s Co nponsai on Insurance carrier and Policy mother am:1
'
.1
' '1Cadiee'•1.
Piilicy Nn:-, '.,
r ♦ t .
CERTIFICATION OP EXEMPTION FROM WORKERS',
•+
... 'r ., COMPENSATION INSURANCE
(TTI 'lion need nal be complete I'f the par Is fen one hlndreJ dao x
'A• ,
' 1 e,Nfy that in II a performance of therk for which this permit is issued, 1
shall not employ troy person in any norner so ds to hec.r a',r )ret to the Workers'
. .
Compensation Lnwx of Calimmiz, Date '
O '
R k bth Cnf t fE pt y old
Ncome
•'
, r
sail W Lt u
become h t lheW A. P 't p : hili l M Code y usl
mi
forth th efinply Ill ran Provisionsar lhspemt, shall heJ erred rv.nked.-
t
CONSTRUCTION LENDING AGENCY
1 herehy a[f Ili t th rot f Jug ,ge , f th perform ce
aE
'Q
of lh kfor wh'ch tl Permit is wood (Sed 3097Civ. C)
t
Lent . N e
..� z
' Turner's Address
U O
f
^ 1 certify that il dal'. p1f t into tlot( ntabove' f al n'
'IY
." .. - ..
- W ILLI
O [)
correct. I g t ply with II and sly' ordinances 'nth t t l ekl g
nth ld gcoasmou'mt ana M1atehY awhor +e rcPro enwf,u dth'sety menter Inn
-' t " ,
t•' S - ` .
then n TIF Hart pmpant, for 'ns dr rip R" sen. t
(We)'gleet J fY adk ph I.,, Ili Gly rC p t 6 nst
..
V9
liabilities. judgments, costs_ d P c h h may any y rte against 'd
City ,sequence of thegranting of da p nt ••
'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS 1, -
Issued by; Date
r ( -
squago, of ApplicvntsCuntractor I - van,
-roofs - ,
•
w
- . HAZARDOUS MATERIALS DISCLOSURE
,Re _'
t
all the applicant or future ambling occupant store ori dl h' a : material
of Roof `
us J f d by theCupar M pal Code Chapter 9.12, aid the H Ith d 5 f ty
,Type ' , - '• + +�
,,
God S ( 25532(.).
f
°Y " °°
All roofs shall be inspected prior to any roofing material being installed. r -
wb fie a,phcsntor Ian Molding occupant Ise equ pm t r t a wh� n
If a roof Is installed without firk obtaining an inspection, I agree to remove
ard(h d cum LVL, aefned by the6ay Ara,A Q.1ty Mnt,genest
strict? y,
i
all new materials for inspection. Applicant understands and 'will comply with
❑Ye, ..,gala,. -
s.�
all non-poilnbsource regulations. .
_•
I have read flambazardims TrucTILIS requirementsunder Chapter 695 of theI
_
California Health &Safety Code, Sed,ns2550525533'vnd 25534 l under stand but
"
-
if Webuildingdoes'racrmently hoocalemmat.than it ismy resWaioddatilym no0fythe.
b,
-
wupnm of the asciduabeir, which aInst he nue, 1ruilciss ane f Cedifidneof
- -
°:`°°'°`Y"Signature
of Applicant - Date
`u
- .- • All roof coverings to be Class"B,,or'.better '-
+
Owner or autnouroad agent. Dntn
OFFICE ,
i• 1 of 1
CITY OF CUPERTINO
BUILDING PERMIT RECEIPT OPERATOR: nancyc
COPY # : 2.
Sec: TWp: Rng: Sub: Blk: Lot:35620003.00
DATE ISSUED.......: 06/26/2000
RECEIPT #.........: 12641
REFERENCE ID # ...: 00060177
:
SITE ADDRESS ...:
11091 BUBB RD
CHECK
198.40
TOTAL RECEIPT
SUBDIVISION .......
VOICE ID
DESCRIPTION
CITY .............:
CUPERTINO
IMPACT AREA .......(
OWNER ............:
VAN BLOMMESTEIN IR4A
-
ADDRESS
CITY/STATE/ZIP ...:
CUPERTINO CA, 95014-4977
:
RECEIVED FROM ....:
TIM
CONTRACTOR .......:
WOOD, LAWRENCE E LIC
# 20810
COMPANY ..........:
WOODS ROOFING '
ADDRESS ..........:
1020 HICKORY CT
CITY/STATE/ZIP ...:
HOLLISTER, CA '95023
TELEPHONE::.......:
(831)637-5576
FEE ID
_
UNIT QUANTITY
AMOUNT PD -TO -DT
THIS REC
NEW HAL
BPERMFEE
-------------
VALUATION ;14,000.00
--------------------
197.00 0.00
----------
197.00
----------
0.00
BSEISMICRE
VALUATION 14,000.00
1.40 0.00
1.40
0.00
:
moPERMIT
o, OF PAYMENT AMOUNT
CHECK
198.40
TOTAL RECEIPT
'=198640
VOICE ID
DESCRIPTION
305 FRAME
601 ROOF TEAR OFF
603 ROOF BATTENS
0
__________ ___ _.------ r. ------_.--_
198.40 0.00 198.40 0.00
NUMBER
------------------
11585
VOICE IDDESCRIPTION
_ . ............................
307 INSULATION)
602 ROOF PLYWOOD NAIL
604 ROOF IN. -PROGRESS
"
CITY OF CUPERTINO-
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
'
BUILDING ADD111,109 I 'BUBB'RDr
{ WOODS ROOFING
ERMULNO: 000E.01.77
.APPLICATION
OWNER'S NALBVAN BLOMMF_ STEIN.. I OMA-
o' 1020' HICKORY GT'V'
1�1b/gd6/2000
IIONF.
('83.1')63'7-5576`
SANITARY NO. _CONTROL NO.
,
n O O
ARCHITECTIENGINLFR.;
y `
Gr
•3• BUILDING PERMIT INFO
EE
+ •M _
r-,
BLDG " ELECT PLUMB , MECH
2 Z
LICENSED CONTRACTOR'S DECLARATION
Job Description' -
pZ_p
Ili by rf thtl airlicenseduncle Prn .' fCh pt 9(bm ne ang
F�pw
wimb t ]oo) rD' nneBa p rv.,n.ca en,y1 m
'ism
SHAKES ,TO COMPOSITION SHINGLES'
�.MfJwJ
�full l 'daft
L¢ Lie
-
6. C m J
Cl
Dat contractor
�3w�
C�0�
ARCHITECTS DCCLARAlIUN
1 J.t d 'hall be hlcrecrd,
.. "
-
- .. / j',' -
<�
yPl used pt
-
7 C C
W�pO
accrue IP t "un'J
,/7/ t -
°' °� o
w
t "r
OWNER BUILDLk DECLARATION'
I hereby aR n that I n e t d fromt Contractor's L L for the
Carlo A
.q V
,I 10 v ,
•k -
d
Toll g . (S t ]0915 H I Prot .. y city at try
,
p�
which q p n construct, II p demolish, r P any It acorn,
priort t 1 q theFPI' tI pe tt I gn l'moment
Sq. Ft. Floor Area
-
(hath I . npursuant,t thep to fm Co, , e L Law '(Chilton,ode)
(w mveeise Bootge Cade),
lig ric dion,
•
An,nr.
emptteadframon
alleged
.1 that '. exempt th f doh, basis for theIl pule pt AYvioPl on-
and the ba
cofSection-70315byaY PPI''tfraP tsubjectstheablo a rapenalty
ofn t thanfsehundred l lls5o0.
( )
- .AP
-
Occu enc Type
P. Y YP
3��r�cID�103. 00 •
-rY
❑IvnownerolPoor cry. or my employees wim wages as their vole w ,Penstion,•
all dr the work and th-.t t t Waited . IYe d f o (Sao ]Oq4
Business and ProfessionsCode TheC t t I 1 d t apply tont
�q� Ulred Inspections
P
305
of preparty Who bolds or imp a fl cot and bar doe4,r ch work himself
— FRAME o t
olr
lnmugh his awn employees provided lnul such improvements not Intended or
'lding
^ — 'I NSULRT I ON"� -
-
offered ( If. h It b p Id. iM1' t, your of
iotplf m bdd will avec h e fP amgmtn Tato, hand or
-
.307'
- - E01` —' ROOF TEAR OFF
mp forpu,.,a efsale). - ,..
- .-�
"
❑I, asmoorofthe property, ame.clusivel'ycarton �hatwith rcensedantiouchater,
602 — ROOF PLYWOOD ''NAIL
k'
'
construct the t (See. 7044, BLsiness,and Professions Calc:) The Conhucta's'an,,
° s n
_
-
603 —; ROOF BATTENS
Law does not apply m tm owner of a candy won builds improves thin the
and who for aa,n ptvimta with, a ,omrnutorla) licensed pursuant to me
and woo us
'f-`; "ROOF 'I
Liecm
LiCeme Laos. Lr
6Qi4' N-PRQGRESS
0 1 an, eta f
❑ l am e.empt adder sea:. , h at P e nor tn'iu rea,on:
x'.
Owner Fin
WORKERSCOMPF,NSAlION DLCLARAl10N;
Iheachyeffirn de pnllY (Perjury ane of the toll ng aedurl n
.. .
1 I have and x ll n vv u n Cert fsvte of Co,een to elf ns re.fo Waken x
t
'ampensm on, as Provided - for by Season 3700 `of the"Lab Code, for ober-
Edofam tcaof the ,r kf hichthisp 1 ,Bed.
❑II d wril°nanmm Workers Comp i I required by Sectio(
Insurance.
9700 of the Code,our the pInsurancee of the work for Much thispermit is
1
Worker's
ed My Worker s Co nponsai on Insurance carrier and Policy mother am:1
'
.1
' '1Cadiee'•1.
Piilicy Nn:-, '.,
r ♦ t .
CERTIFICATION OP EXEMPTION FROM WORKERS',
•+
... 'r ., COMPENSATION INSURANCE
(TTI 'lion need nal be complete I'f the par Is fen one hlndreJ dao x
'A• ,
' 1 e,Nfy that in II a performance of therk for which this permit is issued, 1
shall not employ troy person in any norner so ds to hec.r a',r )ret to the Workers'
. .
Compensation Lnwx of Calimmiz, Date '
O '
R k bth Cnf t fE pt y old
Ncome
•'
, r
sail W Lt u
become h t lheW A. P 't p : hili l M Code y usl
mi
forth th efinply Ill ran Provisionsar lhspemt, shall heJ erred rv.nked.-
t
CONSTRUCTION LENDING AGENCY
1 herehy a[f Ili t th rot f Jug ,ge , f th perform ce
aE
'Q
of lh kfor wh'ch tl Permit is wood (Sed 3097Civ. C)
t
Lent . N e
..� z
' Turner's Address
U O
f
^ 1 certify that il dal'. p1f t into tlot( ntabove' f al n'
'IY
." .. - ..
- W ILLI
O [)
correct. I g t ply with II and sly' ordinances 'nth t t l ekl g
nth ld gcoasmou'mt ana M1atehY awhor +e rcPro enwf,u dth'sety menter Inn
-' t " ,
t•' S - ` .
then n TIF Hart pmpant, for 'ns dr rip R" sen. t
(We)'gleet J fY adk ph I.,, Ili Gly rC p t 6 nst
..
V9
liabilities. judgments, costs_ d P c h h may any y rte against 'd
City ,sequence of thegranting of da p nt ••
'
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS 1, -
Issued by; Date
r ( -
squago, of ApplicvntsCuntractor I - van,
-roofs - ,
•
w
- . HAZARDOUS MATERIALS DISCLOSURE
,Re _'
t
all the applicant or future ambling occupant store ori dl h' a : material
of Roof `
us J f d by theCupar M pal Code Chapter 9.12, aid the H Ith d 5 f ty
,Type ' , - '• + +�
,,
God S ( 25532(.).
f
°Y " °°
All roofs shall be inspected prior to any roofing material being installed. r -
wb fie a,phcsntor Ian Molding occupant Ise equ pm t r t a wh� n
If a roof Is installed without firk obtaining an inspection, I agree to remove
ard(h d cum LVL, aefned by the6ay Ara,A Q.1ty Mnt,genest
strict? y,
i
all new materials for inspection. Applicant understands and 'will comply with
❑Ye, ..,gala,. -
s.�
all non-poilnbsource regulations. .
_•
I have read flambazardims TrucTILIS requirementsunder Chapter 695 of theI
_
California Health &Safety Code, Sed,ns2550525533'vnd 25534 l under stand but
"
-
if Webuildingdoes'racrmently hoocalemmat.than it ismy resWaioddatilym no0fythe.
b,
-
wupnm of the asciduabeir, which aInst he nue, 1ruilciss ane f Cedifidneof
- -
°:`°°'°`Y"Signature
of Applicant - Date
`u
- .- • All roof coverings to be Class"B,,or'.better '-
+
Owner or autnouroad agent. Dntn
OFFICE ,
i• 1 of 1
CITY OF CUPERTINO
BUILDING PERMIT RECEIPT OPERATOR: nancyc
COPY # : 2.
Sec: TWp: Rng: Sub: Blk: Lot:35620003.00
DATE ISSUED.......: 06/26/2000
RECEIPT #.........: 12641
REFERENCE ID # ...: 00060177
:
SITE ADDRESS ...:
11091 BUBB RD
CHECK
198.40
TOTAL RECEIPT
SUBDIVISION .......
VOICE ID
DESCRIPTION
CITY .............:
CUPERTINO
IMPACT AREA .......(
OWNER ............:
VAN BLOMMESTEIN IR4A
-
ADDRESS
CITY/STATE/ZIP ...:
CUPERTINO CA, 95014-4977
:
RECEIVED FROM ....:
TIM
CONTRACTOR .......:
WOOD, LAWRENCE E LIC
# 20810
COMPANY ..........:
WOODS ROOFING '
ADDRESS ..........:
1020 HICKORY CT
CITY/STATE/ZIP ...:
HOLLISTER, CA '95023
TELEPHONE::.......:
(831)637-5576
FEE ID
_
UNIT QUANTITY
AMOUNT PD -TO -DT
THIS REC
NEW HAL
BPERMFEE
-------------
VALUATION ;14,000.00
--------------------
197.00 0.00
----------
197.00
----------
0.00
BSEISMICRE
VALUATION 14,000.00
1.40 0.00
1.40
0.00
:
moPERMIT
o, OF PAYMENT AMOUNT
CHECK
198.40
TOTAL RECEIPT
'=198640
VOICE ID
DESCRIPTION
305 FRAME
601 ROOF TEAR OFF
603 ROOF BATTENS
0
__________ ___ _.------ r. ------_.--_
198.40 0.00 198.40 0.00
NUMBER
------------------
11585
VOICE IDDESCRIPTION
_ . ............................
307 INSULATION)
602 ROOF PLYWOOD NAIL
604 ROOF IN. -PROGRESS