991100340
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991100`3
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBS '
IVISION
INSPECTION DPERMIT EXPIRAnON
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IW DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
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RESIDENTIAL_—ef COMMERCIAL OTHER
OWNER'S ^ ^
HAZARDOUS FIRE AREA
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VES ❑ H yes I understandlyisreq that. Class A
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NAME—
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roof assembly is required.
NO ❑ Initial, LC.B.O. If
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EXISTING ROOF COVERING
ADDRESS—
NUMBER OF EXISTING COVERINGS /
—7
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PHONE { L O L
CONT RZyo�
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NAME Y
TO BE REMOVED TO BE RETAINED
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TYPE
CITYADDRESS B ZIP—61.N %`iJ
EXISTING
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PHONE
PHONE
BUILT-UP ROOF li� �❑
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LICENSE /
EKNUMBER
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ASPHALT SHINGLES
EN ED CONTRACTORS DECIARATION
I hereby affirm that I am 6cansed under provlsions of Chapter 9 (commencing wl h Section
WOOD SHAKES
7000) of Division 3 of the Business and Professions Code, and my license is In full force and
effect.
Llc.
License Claes `-� Num3O beData
\
WOOD SHINGLES
OTHER (SPECIFY), rNO:V�;]544
% � Conctor -
OWNER -BUILDER DECLARATI
I hereby affirm that I em exempt from the Contractor's License Law b the following. reason.
PROPOSED
(Sec. 7031.5, Business and Profession. Code: Any city or county which requires a permit to
construct, alter, khorove, demollsh, or repair any structure, prior to let shu ante, also requires the
BUILT-UP ROOF B Y_0
applicant for such perrmt to fib a signed statement that he is licensed burl to Me provisions
_
of the Contractor's License Lew (Chapter 9 (commencing with Section 7000) of DlvWon 3 of the
'� /�^�s
Business and Professions Code) or that he b exempt therefrom ere the basis for the allegnd
ASPHALT SHINGLES (/_'l_-�Y/w/� •I_yi-�Ift/
exemption. Any vbfatbn of Section 7031.5 by any applicant fa a permit sublects Me eppleant to
e civil penalty of not to than Ilse hundred dollars (S500).):
WOOD SHAKES
❑1, ase rof the property, or my empkryeas with wages as their sole compensates, will do
❑
the work, and Me sWcture Is not intended or offered for sale (Sec. 70 , Business and Proles-
-
stons Code: The Central Lbenee Law does not apply to an owner of property who bulbs or
improyae
WOOD SHINGLES
El
thereon, and who case such work himself or through his own employees, prodded Mat
such Improvements are not Intended or offered for sale. If, fgwo.•ar, the building or Impruvement
is sold within one year of cornpletion, the owner-bu8der will have the burden of passing that he di
OTHER (SPECIFY) ❑
not build or Improve for purpose of sale.).
❑ I, as ower of the property, am exclusWely conbactlng wind dcmwd contractors to construct
the project (Sao 70 , Business and Professions Code: The Contractors Lbenee Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who bulbs or Improves thereon, and who contracts for such projects
with a contmclor(s) licensed pursuant to the Contractors License Law.
-PROVIDE MFGR. INSTALLATION SPECS. '
❑ I em exempt under Sec. ,B 8 P. C. for this reretaile
' Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
,
I hereby affirm under penalty of perjury one of the following declension:
❑ I have and will mabton a Certificate of Consent to sell-hvure for Worker's Compensation,
as provba0 for Try Section 3700 of the Labor Code, for tiro performance of the work for which this
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Building
per Is sasued' -
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Seismic
have end wit meinthln Workers Compensation Ineurarx:o, as required by Section 37W of
Labor Code, for the performance of the work for which MIs permit Is Issued. My Workers
L
pensetbn lI �' Mer end Policy nu r are:
-
Total
n ,
W n �A/>`= � 5
PERMIT AUTHORIZATION
DATE
Carrier Policy No. �/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need net be completed It the peme Is for one hundred dollars (5100) or less.)
I candy that th the perbrmenco of the wwk for which this permit is Issued. I Mall red empty,
any person in any manner eo as to became sublet to the Workers' Conroensatlon Lawn of Call-
All roofs shall be inspected prior to any roofing material bei
ferns'
installed. If a roof is Installed without first obtaining an
Date 4 Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If. after making this Certificate pyj,, -nempflon, you shout become
subject m the Workers' Compeneetlonprovisbno of the Lebo(Cons, you must forthwith comply
Applicant understands and will comply with all non point
PP P Y P
with such pruslslons or this permit shell nd deemed revoked. '-
source regulations.
certify that I have read this applicatlon and state that the above Information Is correct. I agree
to comply with all city and county ordinanoes and state laws relating to bulldig constructionend
All roof covert n S to- be cllaassss.. Or better.
ttw
hereby audxe reprasenMtives of this city to enter upon Ifw above-montetl property for In- '
/
speedos Purposes.(We)
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agree to sane, Indemnity and keep harmless Me C4 of Cupertino against Iledlltles,
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judg I of pn coarct Ina Iaxwns m which may a any way seems against said Cly In coneequanea
SIGNATURE O APPLICANT DATE
PRE -INSPECTION:
PLYWOOD:
IN -PROGRESS:
INSP. DATE
INSP. DATE
INSP. DATE
TEAR OFF INSPECTION:
BATTENS:
FINAL:
INSP. DATE
If DATE
If DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICEICOPY
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
•
BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: Rng: Sub: Blk: Lot:32615075.00
INVOICE DATE......: 11/05/1999
REFERENCE ID # ...: 99110034
SITE ADDRESS .....:
10358 ALPINE DR
SUBDIVISION ....
---------
227.00
CITY .............:
CUPERTINO
IMPACT AREA .......
OWNER ............:
PRM ERNA TRUSTEE
ADDRESS ..........:
ID-----.- DESCRIPTION
•• ---------------
CITY/STATE/ZIP ...:
SAN JOSE CA, CA 95120-1709
CONTRACTOR .......:
PETERSEN, JAMES LIC N 14030
COMPANY ..........:
PETERSEN-DEAN INC
ADDRESS ..........:
7980 ENTERPRISE DR
CITY/STATE/ZIP ...:
NEWARK, CA 94560
TELEPHONE ........:
(510)494-9982
FEE DESCRIPTION CHK
TOTAL FEE
--------------- ---
BPERMFEE P
---------
227.00
BSEISMICRE P
1.70
228.70
1
ID-----.- DESCRIPTION
•• ---------------
FRAME
601 ROOF TEAR OFF
603 ROOF BATTENS
0
3
PAID -TO -DATE BALANCE DUE
-----------
0.00 227.00
0.00 1.70
----------00 -----------
0.
VOICE ID DESCRIPTION
-------------------
307 INSULATION
602 ROOF PLYWOOD NAIL
604 ROOF IN -PROGRESS