99090187 375 33 n 17
PERMIT
' APPLICATION FOR CITY OF CUPERTINO NUMBS
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL ✓ COMMERCIAL ' OTHER
OwNE !� n- - - HAZARDOUS FIRE AREA
r7 t T�C U S"� f+ YES ❑ tl yes—I understand that a Class A
NAME 6 , rL roof assembly is required
,� C� , / ,p NO ❑ Initial I.C.B.O.M
ADDRESS ( �n GLrK-IV H R T V Cy F EXISTING ROOF COVERING
PHONE - NUMBER OF EXISTING COVERINGS
CONTRACTOR'S '
NAME /G.
ILL L) P r r {1 ti 1 I fT PL_ ZIS TO BE REMOVED TO BE RETAINED
-
ADDRESS3 �� cni_ ux -D e. SkN��$ 3 _ COVERING
Tf1'
CSZIP /�l LL.1 7 +"`! EXISTING
PHONE C//0,9) Z 21-/- 90 3 'BUILT-UP ROOF �f
LICENSE
NUMBER ASPHALT SHINGLES
UC ED CONTRACTORS DECLARATION b)/
I hereby affirm Net I em licensed under prwielons of Chapter 0(commencing with Section WOOD SHAKES ❑ /
71l of Division 3 of the Busrl erre Prolessona Code,noun my license is in km force and —,�� IT
effect' #�,g,6 �yj� WOOD SHINGLES � ( Ma
License Clew Q tic.Number lJ
Date �30—/� contractor g11Z P1=041 2� OTHER (SPECIFY) D ❑
OWNER BUILDER DECLARATION PROPOSED SEP 3 01999
1 hereby affirm that I am exempt from the Contragor's License Law for the Iblownng reason.
(Sec.7031.5,Business and Professions Cotle: Any city or county which requires a permit to
construct eller,improvs,demolish.or repair eery structure,prior to Its issuance,also requires the BUILT-UP ROOF ❑
epplknnt for such permlt to file a elgrred statement hat he is licensed pursuant to the provlslons -
of the Contractors Ucoom Law(Chapter 0(cammendrg Min Section 7000)of DMsbn 3 of the � By
Buslnav and Professions Code)or that he Is exempt therefrom and the bells for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil,Penalty
as
of not a pr than five hundred dollarsith wag"
O
I,ea ander of the property,or to ded oremp"eas with wages as c.7 sola compensation,will do
s-
the work,and the structure Is not Intended or altered for sale(Sec.7 r of Business and Profen-
impr es thereon,
The,a n who
License Law tl i s not rapply.toong an owner of property who builds or
improves(hereon/entl who does such work himself or .11,ho his own employees,Improvement
that
Shy
such Improwmante are not p4otl n,or olleretl for sale.It he"the the en of pr a Improvement
is eoltl build
Improve
yearfor purposetlaq lW owner W lkler will have he burden of proving ifol he did
not b 1, or Improve for purpose of eexclu -
El I,as owner of the property,am exclusively contracting with Ikensetl contractors to construct
Na project(Sec.7044,Business and Professions Code:The Contractors License Lew does not LOICEN Shp
apply to an owner of property who Wilds or Improves Malmo,and who contracts for such robacts
with a contractors)licensed pursuant to he Contractors License Law. I PEGS.
❑1 am exempt Order Sec. ,B&P.C.for this reason
Owner Date A ERMIT FEE
WORKER'S COMPENSATION DECIARATION
I hereby affirm under perofty of perjury ane of Ne folkAWrg declaration: f�
as provebySecctwill on 7700 Certificate
f eLaLaborfCoodde88forr to self-asure for Worker's the performance of Ne work farpwhl�chtiNb �, // to
Building'` ro
perms is Issued. '7 O
❑1 have end will maintain Workers Compensation Insurance,as required!by Section 3700 of / Seismic r
M Labor Code,for the perfornwrce of ha work for which this permit 4 Issued.My Workers /� �//1/
aapen
Cdin Insu` car rr ardl Po icy number are. / Total v1 a•SV
Carder ! �' PNIcyNo. l y�0757 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FRDM Wl7RKERS'
COMPENSATION INSURANCE NJ
(This section creed not be completed!ti he permit ie for one hundred counts(St00)or less.)
I certify that in the performance of he work for which his permd Is Issued,I shall not employ
any person In any manner man to became subject to he workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Data Applicart inspection,1 agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making Nle Certificate of Exemption,you should become Applicant UnderStends and will comply with all non point
subject to the Workers'Compensation provlslons of Ne Labor Cade,you must forthwith comply P Y P
MN such provisions or this permit shall be ceamed revoked, source regulations.
I certify Net I have read this application and state that the all Information Is correct.I agree ,,�n(�s�
to compty with all city and ocunty ordinances and state laws retching to building construction,and - All roof coverings to be Class—Or better
hereby authorize representatives of this city to enter upon he atxp a rnenfion kl property for In-
spection purposes.
(We)epee to at Indemnity and keep h was the City Cupertino apaiut Ilebillties, / �J
Judgments,costs and expenses which may In anyny way earns agaiai nst Wtl City In consequence
of the granting of this permit SIGNATURE'OF APPLICANT 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
OFFICE COPY - -
CITY OF CUPERTINO
1 of 1 BUILDING PERMIT RECEIPT OPERATOR: karenb
COPY 4 1
Sec: Twp: Rng: Sub: Blk: Lot:37533017.00
DATE ISSUED... . . . .: 09/30/1999 ,
RECEIPT q..... . . . . : 10202
REFERENCE ID H . . . : 99090187
SITE ADDRESS . . . . . : 18830 BARNHART AVENUE
SUBDIVISION . . . . . . .
CITY . ........ . . ..: CUPERTINO
IMPACT AREA . . . . ...
OWNER ...... . . . ...: D. TRUSTEE
ADDRESS .. . . . . . . ..:
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....: TIM
CONTRACTOR . .. ....: LIC H
COMPANY . . . ....... :
ADDRESS . . . ....... :
CITY/STATE/ZIP ... . .
TELEPHONE ........ :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 4,000.00 97.00 0.00 97.00 0.00
BSEISMICRE VALUATION 4,000.00 0.50 0.00 0.50 0.00
'1•PERMIT 97.50 0.00 97.50 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ____________
CHECK 97.50 1896
.......
TOTAL RECEIPT 97.50
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
•
INVOICE 1b4VOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
J
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: kerenb
Sec: Twp: Rng: Sub: Elk: Lot:37533017.00
INVOICE DATE.... . . : 09/30/1999
REFERENCE ID N . . . : 99090187
SITE ADDRESS . . . . . : 18830 BARNHART AVENUE
SUBDIVISION ..... . .
CITY . . . ........ . . : CUPERTINO
IMPACT AREA ...... .
OWNER . . . ........ . : D. TRUSTEE
ADDRESS .......... :
CITY/STATE/ZIP ... : CUPERTINO, CA 95014
CONTRACTOR ..... .. : LIC 4
COMPANY ......... . :
ADDRESS ....... .. . :
CITY/STATE/ZIP . . . .
TELEPHONE .... . . . . :
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPERMFEE P 97.00 0.00 97.00
BSEISMICRE P 0.50 0.00 0.50
--- 97 50 - - ------
0 -- 97.50
VID -___---DESCRIPTION_-_-_____ VOICE ID ------- DESCRIPTION '
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•