99080164 3 S Z0 3
PERMIT R
b APPLICATION FOR - -7 - CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION Dmw_ PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS A
` -
RESIDENTIAL COMMERCIAL OTHER
OWNER'S rllU�i�+ . . HAZARDOUS
YES ❑ r yes wriblyrsfand that a Claus A
NAME roof faSsemhly is required.
' NO trvtlal LCB.O.f
ADDRESS - 4'� -`�• EXISTING ROOF COVERING
PHONE 0 —4 f s NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
G
NAME TO BE REMOVED TO BE RETAINED
ADDRESS !' n 0i5 L CPE OF ROOF COVERING -
' CITV 8 ZIP J •yam
'/�,p �'{ EXISTING
PHONE 7�0 A1✓6 IS G O • - BUILT-UP-ROOF ID
LICENSE 75 /! -. . f3 �. ��3 3/31/0410 ASPHALT SHINGLE
NUMBER
LICENSED CONTRACTORS DECLARATION I 3 •I f1f1
I hereby affirm that I am licensed under pradsfors m
of Chapter 8(commenting with Section WOOD SHAKES 1 I Je7
7000)of DMslon 3 of Me Business and Professions Code,and my license Is In full force and
sited.
WOOD SHINGLES
Ucerse Cl "" Uc.Number ,�
Date G AVID Cant aaar • OTHER,(SPECIFY)
OWNER-BUILDER DECLARATION - PROPOSED
I hereby affirm that I am exempt Iron the Contractors License Law for the following reason.
(Sec.7031.5,Business atld Professions Code: Any cry,or county which requlres a Permit to BUILT-UP ROOF
conr appl two,alter,Improve,dente a6ionrepelrernstructure,prior toits issuance,whorequiresthe %
applicant for each Perr^r to Ills a atoned statement that he Is Ior to it d ssuance,fo ma proviquiresone
of the Concesclore License Law(Chapter S(commencing with Section 7000)of Dlvlelon 3 of the
Business and Protestations Code)or that he is exempt l srafrom and the basis for me alleged ASPHALT SHINGLES
exemption,Any violation of Sactlon 7031.5 by any applicant for a permit Subjects the applicant to
a civil penally of not more than fivehundred dollars(5500).1:
❑I,as owner of the property,or my employees with wages as their ads compensation,will WOOD SHAKES ❑
Me work,end Na SVmwre Is rot Intended or offered for sale(Sec.7040,Business and Profes-
sions Code:The Contrectors UcenAe Law does ret appy to an owner of property who builds or WOOD SHINGLES
ImproveS maroon,and who does such work himself or through his own employees,provided that - ❑
such Improvement;are not Intended or offered for sale.If,however,the WIding or Improvement
Is soldwlmin one year of completion,the owner-bullder will nava the burden of proving that he did OTHER (SPECIFY)
not bull or Improve for purpose of Sell.).
❑I,as owner of the property,am exduslNely contmding with licensed contractors to catstr
me project(Sec.7044,Business and Professions Code:The Contractors Ucerss Lew does not PROVIDE I.C.B.O. REPORT NO.
appy to an awmr d praperry who builds or Improves lherson,and who centaxos for such projects
with a contractor(s)licensed pursuant to me Conuanorb License Law. PROVIDE MFGR. INSTALLATION SPECS.
]1 am exempt under Sec. ,B 8 P.C.for this reason
o«ner - Dee
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under pacaity of perjury we of me fallowing detiaratlon:
❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation,
as prodded for by Section 3700 of the Labor Code,for the performance of the work for which m19 ! g
permit Is Iss d. o (.( SBIS IC
I here and will maintain Worker's Compensation Insurance,as required by Sooloh37M of
the Labor Code,for me performance of the work for whkn this permit is Issued.My Workers
Compensation Insurerlca comw and Policy number are: Tot
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM MRKERS'
COMPENSATION INSURANCE N.C.] .
(This Section new not as completed r Ie parmh is for one hundred delete($100)or lees.) -
I certify that In the perbrmerlce of re work for wNch this peratt Is leaned,1 steel not employ
any paraun Ina manner eo as to became auaect to the Wwkens Compensation Laws of Carl- All roof^.shall be inspected prior to any roofing material being
forme. installed. If a roof is installed without first obtaining an
Date Q Applicaln inspection,I agree to remove all new materials for Inspection.
NOTICE TO APPLICANT: It,after making IIS Cowficp of ExamplkX,you should become 'Applicant understands and will conn I with all point
Subject to the Workars'Compensaron proddone of me Labor Cade,you must forthwith comply PP P Y P
with such prodslon5 or Ile permitSheiQbe ceemed hawked. Source regulations.
I certity mat I have read this application and State that the above Information Is coned I agree �Q
to campy whir all city and county ordinances and state lam relating to bolding construction,ad All r00f COVerin SI be Class M Or better.
hereby authorize mpreeenlhws of this cly to anter upon me above-mentioned property for In.
spade)Wrtoo
(We)agree to cave.Indemnity and keep lftarnn�essway accrue
of st satire against Iladllllee, •\�!!f/Jl
Judgmento,rose and expenses which they I e1ry way setae apalnet esti Clry I coreequexe
d the granting of this pahmn. SIGNATURE APPLICANT DATE
PRE-INSPECTION:. - PLYWOOD: - IN-PROGRESS:
,INSP. DATE INSP. DATE INSP. DATE•
TEAR OFF INSPECTION: BATTENS: 1 FINAL:
INSP. DATE INSP. DATE INSP. DATE
NOTE:- OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
• OFFICE COPY
CITY OF CUPERTINO
I. 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: kacenb
COPY p 1
Sec: Twp: Rug: Sub: Elk: Lot:37526036.00
DATE ISSUED.... .. . : 08/23/1999
RECEIPT #...... . . . : 9882
REFERENCE ID # .. . : 99080164
SITE ADDRESS .... . : 18631 BARNHART AVE
SUBDIVISION ... . .
CITY . ........ . .. .: CUPERTINO
IMPACT AREA .. . . ...
OWNER ....... . . . ..: HOOK
ADDRESS .... . . . . . .:
CITY/STATE/ZIP . . .: CUPERTINO, CA 95014
RECEIVED FROM . . . . : TIM
CONTRACTOR . . . . . ..: MCCARTHY JR, MICHAEL LIC # 21043
COMPANY .... . . . ...: MCCARTHY INDUSTRIES INC
ADDRESS .. . . . . ..... 845 COMMERCIAL ST
CITY/STATE/ZIP ... : SAN JOSE, CA 95112
TELEPHONE . .. ..... : 4084361560
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS RED NEW BAL
__________ _____________ __________ __________ __________ __________ __________
BPERMFEE VALUATION 7,000.00 127.00 0.00 127.00 0.00
BSEISMICRE VALUATION 7,000.00 0.70 0.00 0.70 0.00
TO PERMIT 127.70 0.00 127.70 0.00
M OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 127.70 10138
------------
TOTAL RECEIPT 127.70
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
........ ............................ ........ ............................
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
MCCARTHY INDUSTRIES INC 99080164
•18631 BARNHART AVE 845 COMMERCIAL ST 08/23/1999
SAN JOSE, CA 95112
HOOK 21043
ROOF
0 $6151
37526036. 00
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