99110094 '3Lq I q - 6 ) (0
A Pw ir-
. FPERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER 4_40�
INSPECTION nIVIqIi PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 183 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALUED INSPECTION
BUILDING ADDRESS
1`6 2- L Aa lil,, qvjuog AveRul� RESIDENTIAL X COMMERCIAL—OTHER—
OWNER'S HA7AF3DOUS FIRE AREA
YES Ifyes-lunderstandthataClarsi
NAME /?Prf toof assenn"y is requi
I NO Inithal— I.C.B.O.
EXISTING ROOF COVERING
ADDRESS `10 Z� bIA210�woo`Y) AVV-�u!16
PHONE NUMBER 0 F EXISTING COVERINGS
CONTRACTOR'S TO BE REMOVED TO BE RETAINED
NAME T\ C
ADDRESS TYPE OF R0,0000VERING
CITY&ZIP I
EXISTING
PHONE BUILT-UP ROOF
LICENSE Y2 �m Tfol's
NUMBER ASPHALT SHINGLES
UCENSED CONTRACTORS DECLARATION
I hereby affirm th at I am licensed under prDAeons of Chapter 9(common&Ing wfth Sooffort WOOD SHAKES
7")of Dridalch 3 of the Business and Profteenbhu Code,and my kerzi Is In full force and
afteurt.
Uc Num,, 72 -7591 WOOD SHINGLES
License CU Its D
Date 15RI 4�ff iiii
OWN(RI NOF 1 6 1999
oh�
I hereby M.that�am exempt fro onmactor f
(Sec.7031.5,Business and Proftesions Code: Any city or county which req.1,
y
'm LB El
cort trttcl,alter, micho,,e,demolish,or 1 it uIr
par e,p r,'o, a —7
of Me Contractor's I Law(Chapter 9(c 7: 5
ri for such pentrut to file a aign led ifte',:ZS=.uft a I.lot By El
"m"n" �hWlft
Business and Professions Code)or Mat he 1,e.4 rofrb� 11W I I INGLES
examotibri.Any violation of Section 7031.5 by
a cMl Penalty of not more than five hundred dollars($500).):
1,as owner of the property,or my emp as with we,, a
aV. for as
a r:J
the k. nd the Wn,clure In not Intended! apply it 2-F
sions Cod Tithe Contrinct.r's Licons._x.
�mr,h=lf.o�imho
ini taereon,ark!who uIbes
si Immovornerts are not intandec!or oflort lo"
asod'thin�year of compiloi the owner-Wiloter will 'da infir
not Wild Or irl for pitrPOSA of soula.). FY) El
E]1,as owther of he property,am exclusi contracting with licensed contrectors to construct
the profti(Sao 70�.Business and Prouseskhs Code The clstritractor.License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Wilds or trivubI thereon.and who commands for such prolms
with a conthadoi liceneed!pursuant to the Contractors Ucerse,III
0 1 am exempt urrucker Sm. — B I P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
Owner [)at.
WORKERS COMPENSATON DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under ponafty of penury one of the following declziratiort
0 1""and will maintain a Certificate of Consent to saill-Insure for Workers Compensation, Building
as pr�lklml for by Section 37M of the Labor Code,for the performanrce of the work for which this
permit Is Insum.
>-,Iliha�o and.111 maintain Workers Cornwisation Insurance,as required by Section 3700 of Seismic
V Liloor Code,for the performance of trus work for which this permit is wum,My Workers
rompennationl Total /0�17 . r7
Carrier tij;:Z7icy number are:Polcy No"Ill .�L)00 1� PERMIT AUTHOR 17ATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE NCQ
(This sectfon nem!mut be completed it Me permit is for one hundred dollars($I W)�less.)
I cortity,that In the perimmarka of the work for which this Permit is Issi I shall mit employ
any person In any mannar so ars to become ullow to the Workers'Gompormsembi Laws of Call- All roofs shall be inspected prior to any roofing material beihg
loml.. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOI TO APPUCAW. 11,after making this Certificate of Exampflo,you sruckilci bmome
.ulnject to the Worors'Componsation pundsions of the I-abor Coots,you must forttrafth comply Applicant urft�effrstands and will Comply with all non point
with such prordslons or this parmit stroll cks deemed heribluni source regulations.
I certify met I him read this application and state that the�Infcirmatlon 1.correct,I agree
to comply with all city and county ordInartures end state lam miating to buildlnp consth-rction,and All roof coverings to be class 16 or better.
hereby authorize repronantatirms of this city to emor upon"ai�menuionusdl property for In-
spection purporuss.
(We)agree to ii ln&mnfty and keep harmless the City of CuipertmO against ltablhb.
ju%.
,h...1,amd expen..wri may In any my accrun,against said City 11 comsequ. N--_��TURE�PLIICANT DATE
of I granting of this bermil.
PRE-INSPECTION: PLYWOOD: - IN-PROGRESS:
INSR—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
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: Rng: Sub: Blk; Lot:3691701G.00
INVOICE DATE...... 11/17/1999
REFERENCE ID # ... 99110094
SITE ADDRESS ..... 902 BLAZINGWOOD AV
SUBDIVISION ......
CITY ............. CUPERTINO
IMPACT AREA ... .. .
OWNER .......... . . HENNEUSE PAUL R JR AND C P
ADDRESS ....... . . .
CITY/STATE/ZIP . . . CUPERTINO CA, CA 95014-4619
CONTRACTOR .. . . . . . LIC #
COMPANY .. . . . . ....
ADDRESS . . . . ......
CI�Y/STATE/ZIP ...
TELEPHONE ........
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPER14FEE P 127.00 D.00 127.00
BSEISMICRE P 0.70 0.00 0.70
--------- ------------ -----------
127.70 0.00 127.70
ID DESCRIPTION VOICE ID DESCRIPTION
..... ... ..........
5 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS