99100097Z
•
I*
COPY
7
APPLICATION FOR . CITY OF T
INSPECTION DIVISION PERMIT EXPIRATION
:REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
-
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
10379,1irGW6QW,
- -
RESIDENTIAL " COMMERCIAL OTHER
OWNER's
HAZARDOUS FIRE AREA
� �
e
VES ❑ B yea
req fhat a Dlass A . '
NAME r1L-AI"fieri �}GC17�,i
-sambas
roof asernbly is required.,
NO ❑ IrWal I.C.S.O. k
Air6WO%QT^ Qt2, C4MQi1n0. CIES'
EXISTING ROOF COVERING
ADDRESS
,I'D319
PHONETO$'132 3
NUMBER OF EXISTING COVERINGS
- -
CONTRACTORR''S,,
-' �,�,,�.
NAME All SC.(.�I 1� C'Cua'IWA �VI CSS
TO BE REMOVED - l TO BE RETAINED
ADDRESS��Oe12,1 h Ci511 1
TYPE OF ROOF COVERING
CITY B ZIP , W ,' .�SC
EXISTING
S
PHONE
❑ '
-BUILT-UP ROOF,,LICENSE
NUMBER 155? / - 03S
ASPHALT SHINGLES
WOOD SHAKESr�—��j
L ENSED CONTRACTORS DECLARATION
I ereby affirm that I em licensed under provisions of Chapter B wmmencing with Section
7000) of DMslw 3 of me Business end Professions Code, and my Skeme is In tug force and
effect.Q
LJ
OD SHINGLE
Gpa '.Lk.
❑
•.
License Cha/ps
Number.' 11, [669`0x21 ( (',r
J OCT 1 •l0 q.
PEC'
Date 1 .3Idi 1 Conircctor la`^^.�c.��n �+^""••1��
OWNER -BUILDER DECLARATION
Ii
I hereby affirm that I am exempt from the Contractors License Lew for the following reason.
(Sac. 7031.5, Busnws and Professions Code: Any city o county which requlre5 a pamdi to
n
P,y
construct, alter, Improve, demdleh, or to pair any structure, prior to ltd Issuance, also requires the
"BUILT UP ROO
applicant for such permit to file a signed Statement mat he Is licensed pursuant to Ne prodofons
of the Contractors License Lew (Chapter B (commendrg with Section 7000) of Division 3 of me
ne
aProfasalons Code) met he le therefrom me basis for
-
or exxnpt end the alleged
ElBusiness
ASPHALT SHINGLES
exertption. Any violation of Section 7031.5 by any applicant for a permit subjects me applicant to
a cMl penalty of not more men five hundred dollars (5500).): ,
1, owner the Mor We do
WOOD SHAKES ❑
C-] as of property, or my emp"s with wages as compensation, will
the work, and the structure Is not Intended or offered for sale (Seo. 70x4, Business and Proles-
sions Cade: The Comrac1ora Llconas Law dose rot apptyto en owner of propertyw balms or
WOOD SHINGLES ❑
Improves Mareon, and who does such work himself or through his own employees, provided that
such Improvements are not Intended or offered for sale. tl, however, the building or Improvement
Is edtl within one year of completion, me owner -bulkier will he" Me burden of provlrq that he tlfo
OTHER ��Is�•r-��
(SPECIFY)
1
not build or Imprfor purpose of sale.). -
❑I, asownarof the property, em exclueMycontnutln with licensed contractors t6mrstruct
PROVIDE I.C.B.O. REPORT NO. 17 )O
the Prom (Sec.7044, Business and Professions Code: tQM Contractors Ucense Law does not
apply to an owner of property who Wilde or lmprovwe thereon, and who contracts for such projects
with a contractor(e) Ilcaraed wrauam to the Contractors I -cense law.
-
PROVIDE MFGR. INSTALLATION SPECS.
❑ I em exempt under sac. B a P. C. for mla reason
Owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I�/i31gq
I hereby alllrm under penally of perjury one of the folkrWrq declaration:'
'❑Ihavaand will maintain aCertificate ofConsent tosalf4ruumfor Worker.6Compensation,
as arwided for by Section 3700 of the Labor Code, for the of rhe work for witch m4
Iag.,18
Building
performance
perm Is Souse.
$BISmIC
have and will maintain Workers Compensation Insurance, as requited by Section 3700 of
- Labor Code, for the performance of the work for which this pemMt is Issued. My Workers
Compeasetl
Total
n Inwrance cemler and Polley number aro:
VI IIQn a✓G Policy 0 g
carrier No.
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM YORKERS' '
COMPENSATION INSURANCE N.CQ
' (This Sedfon need not be completed If the pamdt Is far one hundred dollars ($100) or Iasi.)
�nJ��•L,L� Lf
I certiy met In me pedorrne. of me work for wmkh this permit is Issued. I shell not amp oy
any parson In any manner en ss to become Subject tome Workers'Compensetlon Lewy of=Y
All roofs shall be inspected prior to any roofing material being
0rt °
installed. If a roof is installed without first obtaining an
Data ApplIcam
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making ins Certificate of Exemption, you should became
Subject to the Workers' Compensation provisions of me Labor Code, you must forthwith comply
Applicant understands and will comply with all non
pp p Y point
with such provisions or MIS permit shalgbe deemed revoked.
source regulations.
I earthy mel l have read MIS application end State that me above Information is correct. I agree
to Comply with all dry and county ordinances and state laws relating to Wilding constmoion, and
All roof coverings to be class "C" or better.
hereby authorize repreawneW Wes of MIS dry to enter upon me above-mentioned property for in.
spoctbn purposes.
L1
(We) agree to afros, Indemnity ane keep harmless me City of Cupertino against Ileblilties,
/ �� q-3-
. judomenm, were and expenase which they In any way same against said Clry In consequence '
l t e grentln of this permit.
011
SIGNATURE OF P LIOANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
COPY
a
CITY OF CUPERTINO `
Item 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: nancyc
COPY # : 1
Sec: Twp: R g: Sub: Blk: Lo[:32613112.00
DATE ISSUED.......: 10/19/1999
RECEIPT 4.........: 10376
REFERENCE ID # ...: 99100097
SITE ADDRESS .....: 10379 AINSWORTH DR
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: KEENLY KATHLEEN W
ADDRESS ...........
CITY/STATE/ZIP ...: CUPERTINO CA. CA 95014-1002
RECEIVED FROM ....: TIM
CONTRACTOR .......: GORSHTEIN, VLADISLAV LIC # 21035
COMPANY ..........: ALL SEASONS ROOFING SERVICES
ADDRESS ..........: 2640 PACER LN
CITY/STATE/ZIP ...: SAN JOSE, CA 95111
TELEPHONE ........: 40B99244SS
WID UNIT QUANTITY AMOUNT
B: EE VALUATION 13,000.00 187.00
BSEISMICRE VALUATION 13,000.00 1.30
TOTAL PERMIT 1B8 30
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ____________ -----
CHECK 188.30 10650
••••
TOTAL RECEIPT 188.30
VOICE ID DESCRIPTION
305 FRAME
601 ROOF TEAR OFF
603 ROOF BATTENS
PD -TO -DT THIS RED NEW DAL
____ __________ ----------
0.00 187.00 0.00
0.00 1.30 0.00
0.00 198.30 0.00
VOICE ID DESCRIPTION
307 INSULATION
602 ROOF PLYWOOD NAIL
604 ROOF IN -PROGRESS
ICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: nancyc
Sec: Tp: Rng: Sub: Blk: Lot:32613112.00
INVOICE DATE......: 10/19/1999
REFERENCE IO N ...: 99100097
SITE ADDRESS .....: 10379 AINSWORTH DR
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: KEENLY KATHLEEN W
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-1002
CONTRACTOR .......:
GORSHTEIN, VLADISLAV LIC # 21035
COMPANY ..........:
ALL SEASONS ROOFING SERVICES
ADDRESS ..........:
2640 PACER LN
CITY/STATE/ZIP ...:
SAN JOSE, CA 95111
TELEPHONE ........:
4089724455
FEE DESCRIPTION CHK
--------------- ---
BPERMFEE P
BSF,ISMICRE P
VOICE ID DESCRIPTION
305 FRAME
601 ROOF TEAR OFF
603 ROOF BATTENS
0
TOTAL FEE PAID -TO -DATE BALANCE DUE
--------- ------------ -----------
187.00 0.00 187.00
1.30 0.00 1.30
188.30 0.00 188.30
VOICE ID DESCRIPTION
307 INSULATION
602 ROOF PLYWOOD NAIL
604 ROOF IN -PROGRESS
0