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99100049 Z 2- d oC qq100G4-q PERMIT R_ APPLICATION FOR . CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED Wlml 180 DAYS OF PERMIT ISSUANCE OR _ 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESSQ D , ( � RESIDENT( COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA /-,// YES L] N yes-I understand dial a Class A NAME ' / /� fl/ � - roof assembly is required. NO ❑ Irdhal I.C.B.O.tl _ ADDRESS , eLlz EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS CONTRACTOR'S TO BE REMOVED TO BE RETAINED NAME ADDRESS S�o /1n1 ,^�„� �,� ' TYPE OF ROOF COVERING CITU BZIP „/ �!C (/A PHONE yD FQ3 l9?o Q SA ti :7_0J'If EXISTING BUILT-UP ROOF ❑ LICENSE NUMBER Z IF Z G ASPHALT SHINGLES DCamund CONTRACTORS DECLARATION n hereby eloaffirm that em fwensetl under Prostions of Chapter S(commencingnso isI with f form and WOOD SHAKES /OI 7000)of Dlvblon 3 of the Buslwsa ertd Professions Code,end my Ikon;e b In lull force entl effect. - WOOD SHINGLES Lksn;e Close'(f__ Uc.Numbar Date Contredc - OTHER(SPECIFY) ❑/n'. OWNER-BUILDERD LARATI PROPOSED - hereby a11lnn that am exempt from the Con Vectors or county w for p reason. D (Sec.7031.5,Business am Professions Cotle: Any city or county whi qulr9s a permit to construct,after,improve,demcllsh,or repair any structure,prior to Its I me,also requires the BUILT-UP ROOF ❑T 81999 applicant for such permit to its a signed statement that he is licensed pursuant to the provisions of the Contractors Ucenm Law(Chapter B(commencing with Section 7000)of Division 3 of the Business and Profeaslma Code)a that he is exempt fherefrom em the basis for the alleged ASPHALT SHINGLES By a dvil Pen.My f not m n of Section 7031,5 re by any applicant for a permit subjects the eppllmnt to e am penblty of not more than Me 031,5 b any a pman.): ❑I,ns owner of the property,w my employees with wages as their sole compensation,will do WOOD SHAKES Me work.and Me al ucture Is not intended or offered for said(Sec.7044,Business and Profea- Mone Code:The Cg tractor's Ucense Law does not appy to an owner of property who bulltls w WOOD SHINGLES El thoraco,and who does such work himself or through his ovum employees,pmvlded that such Improvements are not Intended or offered fon sale.If,however,the building or Improvement Is sdtl within we year of completion,the Avner-Wilder will have the burden of proving that he did OTHER (SPECIFY) ❑ not Wild or Improve for purpose of sale.). ❑I,as omor.of Me property,am exclusively contracting with Ilmnae i contractor;to construct Me project Sec,7044.Business and Pmfwcons Code:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of property who bustle or Improves hereon,am lou contracts for sum projects with a contrector(s)licensed pureuent to the Contractors License law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt urWar Sec. ,B 8 P.C.for this rw;ort Owner Data APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following dedemflon: [—Y 7 (w ]1 have and wM maintain a Certificate of Consent to sell-Insure for Workers Compensation, Building 'an travel for by Section 3700 of the Labor Cade,for the performance of the work for which this r permh Ins Is .ed. J c7 Seismic O ❑1 have and will maintain Workers Compensation Insurarwe,as requl red by Section 3700 of the Labor Code,for the perfwmanm of the work for which this permit Is issued.My Workers / f�•� Compensu flon Insurance carrier and Policy number are: Total /.®7 /J .. center A" r O/L � 07/3 POIIcy No. /� � v PERMIT AUTHORIZATION DATE CERTIFICATE OFEXEMPTION FROM WORKERS' Z M COPENSATION INSURANCE N.CQ - (Thls sectlm need not be completed if the permit is for one hurrdred dollars($100)or lees.) I cattily that In the performance of the work for which this polar Is issued,I shall rpt employ C V any person In arty manner so as to become subject to the Workers'Conspemsatlon Laws of Call- All roofs shall be inspected prior to any roofing material being fornla. installed. If a roof is installed without first obtaining an Data Applicant inspectional agree to remove all new materials for inspection. Nonce a orkam'APPUCNrnnewakamaking v�w�w the�ofyou Exemption,�foena,�oaoomN Applicant understands and will comply with all non point eu NO to the WOMery with such provisions or this permit shall be deemed revoker. source regulations. I warty Hutt I have read this application and state that Me above information Is maw.I agree to comply with all city am county ordlaances aro state laws relating to Wlding construction,oral All roof coverings t ech8 rbetter. hereby authorize representatives of Wa city to enter upon the above-mentioned property for Ir, spedlon purposes. (We)agree to save,Indennly and keep harmless Me Gly of Cupertino against Ilabllltlea, Judgments,male and expenses whim may h em way accrue egalut able City In consequence S U F ICA DATE of the granting of this permit. - - PRE-INSPECTION: PLYWOOD: IN-PRO : 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: yvonnek COPY N 1 Sec: Tp: Rug: Sub: Blk: Lot:32602006.00 DATE ISSUED. . . . . . . : 10/08/1999 RECEIPT q... . . . . . . : 10284 REFERENCE ID # . . . : 99100049 SITE ADDRESS . . . . . : 10980 BARRANCA DR SUBDIVISION . . . . . . . CITY . .. . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER .. . . . . . . . . . . : SHAWN RAW ADDRESS . . . . . . . . . . : 10980 BARRANCA DR CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-0102 RECEIVED FROM . ... : TIM CONTRACTOR . . . . ... : STEFFENSON JR, JIM LIC h 19668 COMPANY . . ........ : HOMEGUARD INC ADDRESS . . . . ..... . : 510 MADERA AVE CITY/STATE/ZIP .. . : SAN JOSE, CA 95112 TELEPHONE ... . . . . . : (408)993-1900 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW HAL _______ ________ __________ __________ __________ __________ BPERMFEE VALUATION 5,000.00 107.00 0.00 107.00 0.00 BSEISMICRE VALUATION 5,000.00 0.50 0.00 0.50 0.00 0 PERMIT 107 50 0 00 10.50 0.00 METHOD OF PAYMENT AMOUNT NUMBER _________________ ____________ ----------________ CHECK 107.50 25199 n. TOTAL RECEIPT 107.50 VOICE ID DESCRIPTION VOICE IO DESCRIPTION -------- ------------- -------------- ........ ............................ 305 FRAME 307 INSULATION 601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 603 ROOF BATTENS 604 ROOF IN-PROGRESS • i INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE CITY OF CUPERTINO • BUILDING PERMIT INVOICE OPERATOR: yvonnek Sec: TWp: Rng: Sub: Blk: Lot:32602006.00 INVOICE DATE. . . . . . : 10/08/1999 REFERENCE ID # . . . : 99100049 SITE ADDRESS . . . . . : 10980 BARRANCA'DR SUBDIVISION .. . . . . . CITY . . ....... . . . . : CUPERTINO IMPACT AREA ... . . . . OWNER . . . ..... . . . . : SHAWN RAW ADDRESS . .... . . . . . : 10980 BARRANCA DR CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-0102 CONTRACTOR . . . . . . . : STEFFENSON JR, JIM LIC 4 19668 COMPANY . . . . . . . . . . : HOMEGUARD INC ADDRESS . . . . . . . . . . : 510 MADERA AVE CITY/STATE/ZIP . . . : SAN JOSE, CA 95112 TELEPHONE .. . . . . . . : (408)993-1900 NOTE: THE FEES LISTED ARE ONLY THOSE DUE BEFORE PERMIT PRINTING FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE --------------- --- --------- ------------ ----------- BPERMFEE P 107.00 0.00 107.00 BSEISMICRE P 0.50 0.00 0.50 --------- ------------ ----------- • 107.50 0.00 107.50 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 r •