99090035 , oq Obi
3 75 ^ 3 3Z— PERMIT
APPLICATION FOR CITY of CLIZ7.O .. NUMBER R" 6650
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (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 - � '
f • '" RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
4
p� / VES ❑ 11 yeaunderstand tired a Claw A
sof assembly is required.
NO ❑ Intel � I.C.B.O.N
ADDREss r EXISTING ROOF COVERING
PHONE fl NUMBER OF EXISTING COVERINGS _
CONTRACTO / . i
TO BE REMWED TO BE RETAINED
NAME
ADDRESS - �� TYPE OF ROOF COVERING
CITY B ZI uisTING
PHONE&.50 K7,J�b J/3 9 .
BUILT-UP ROOF
LICENSE p2 7�0
NUMBER ASPHALT SHINGLES
UU
UCENSED CONTRACTORS DECLARATION
hereby Iso n that em Business
under Professions
of Chapter a(commencing with f Sean WOOD SHAKES
7000)al Division 3 0l thelivens ark erofasel Ion Cools1.,ab my license a In lull force and
effect. '
� WOOD SHINGLES
Uceree Number Cleve Uc.Nuer
OTHER(SPECIFY) El
Date Con tor,
OWNER-BUILDER D:CLARATIOV
PROPOSED .
I hereby affirm that I am exempt from fire Contractors Ucense law far the Jai reason.
(Sec.7031.5,Business and Profe"lons Code: Any city or county winch requires a permit to
mf
nvtmct,after, repair any structure,prior to its Issuance,aisp requires the BUILT-UP ROOF
- appkcant for such permit to file a signed statement that he st licensed pursuant to Me provisions
of Me Contractors License Law(Chapter 8(mmmendnp with Section 7000)of Divblon 3 of the Q
Business and Professiene Code)or that he Is exempt therefrom and the basis for the alleged . ASPHALT SHING ❑ I
exemption.Any violedon of Section 7031.5 by any applicant for a permit subjects Me applicant to
a civil penalty of not more then five hundred dallare($500).):
❑I,as owner of the property,or my emplayeas with wages(their sole compensation,will do WOOD SHAKES SF 'a1gg9
the work,and the structure is not Intended or offered W vele Sec.7044,Business and Pmfee- SEP � v
sicrea Code:The Contractors License Law,does not apply to an owner of property who Wilds Or WOOD$HINGE
improves thereon,and who does such work himself or Mrough his awn empkryees,provided that
El
such Improvements are not Intended or offered for We.If,lfi e e the Nlfdinp or Improement
Is coo within one year of completion,the owner-budder Mil have the Nrtlen of proving that he tlid OTHER (SPECT y�-�
not WHO or Improve for purpose,of sale.). -
❑I,as owner of Me properly,em exdualvety contracting with licensed conVactore to construct
Me project(Sec.7044,Business and Professions Code:The Contractore Uc: ae Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who W lOe«Imprpes thereon.and who contracts for such projects
with a aomrector(a)Ibensed pursuant to the Contractors Ucense law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B&P.C.to,this reason
Owner _ Date
WORKER'S COMPENSATION DECLARATIONAPPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of Me following dederation: r� f\
❑1 have and will maintain a Certificate of Camenl to wif-Insure for Workers Compensation, .f� Building 1 ) UV
els provided for by Section 3700 o1 the Lebor Code,for Me performeroe of TO work for which this / g
pLaloomit Is lseuetl. $61SLTIIC �1LlL
C/ln7p(Lheve and MII maintain Workers Compensellon Insurance,as required by Section 3700 of ` 3 7 d(�/ OlA ,l(./l
thyLab«Code,for the performance of Me work far which tine permit Is lesueo.My Worker's
eneetbn Inrazd ley nu ere: r TOIa
Carrier Pal No. -J 6 /ZS - PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE rn
(This section MW rot he completed If the permit Is for one hundred dollars(5100)100)or IeasJ \ I\ Q
1 certify that In the performance of the work for which dulls parmll le Issued.I shell not employ
any person In any manner w as to became suet o the Workers'compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
forma. a installed. If a roof is installed without first obtaining an
Date- 7 AppHOanl ' - inspection,I agree to remove all new materials for inspection.
NOTIC AP LICANT: ll,after making this Cantata f Exempdan,you should became Applicant understands and will comply with all non dint
subject to the Workers'Compensetfon provisl«ts of the «Code,you must Iarihvdth comply pP P Y P
with such prwfelons or this permit shell be deemed revoked. source regulations. -
1 certify Mat I have two this application and state that the above Information le correct.I agree
to comply MM all city and county ordlnences and state laws relating to building construction,entl All roof coverings to be Class or'better.
hereby authorise reffresematives of this city to enter upon the above-mentioned property for in. u
spectlon purposes.
(We)agree to neve, mems w and day i harsh y Me City of st sartlro epelnel Ilebllltlee, -
jWamenLq costa mrd expenses which may M any way accrue against mltl Clry n coneequeroe
of ge granting d this permit. S NATU OFA APPLICANT AT
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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION.
OFFICE COPY
INVOICE IMOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: karenb
Sec: Twp: Rng: Sub: Blk: Lot:37539032.00
INVOICE DATE. .....: 09/03/1999
REFERENCE ID q ... : 99090035
SITE ADDRESS .....: 942 BROOKGROVE LA
SUBDIVISION . . .....
CITY .... . . . . . . ... : CUPERTINO
IMPACT AREA . . . . ...
OWNER ...... . . . . . . : SALINIA LIU
ADDRESS ... . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4668
CONTRACTOR .... . . . : COSMOS, RICHARD LIC # 18844
COMPANY ...... . . . . : COSMOS ROOFING
ADDRESS ....... . . . : 450 SAN ANTONIO RD
CITY/STATE/ZIP . . . : PALO ALTO, CA 94306
TELEPHONE ...... . . : (415)493-6373
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
BPERMFEE P 117.00 0 00 117.00
BSEISMI CRE P 0.60 0.00 0.60
--------- ------------ -----------
117.60 0.00 117.60
V :D .-....--DESCRIPTION VOICE ID --_-__.DESCRIPTION
....... ........ . ...................
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•
CITY OF CUPERTINO
I� 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: karenb
COPY 9 1
Sec: Twp: Rng: Sub: Blk: Loc:37539032.00
DATE ISSUED. . . . ...: 09/03/1999 '
RECEIPT W. . . . . ....: 9985
REFERENCE ID 0 ...: 99090035
SITE ADDRESS .....: 942 BROOKGROVE LA
SUBDIVISION . ......
CITY ..... . . . .....: CUPERTINO
IMPACT AREA .......
OWNER ... . . .. ..... : SALINIA LIU
ADDRESS . ......... :
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4668
RECEIVED FROM .... : TIM
CONTRACTOR ....... : COSMOS, RICHARD LIC 4 18844
COMPANY ......... . : COSMOS ROOFING
ADDRESS ...... . . . . : 450 SAN ANTONIO RD
CITY/STATE/ZIP . . . : PALO ALTO, CA 94306
TELEPHONE .... . . . . : (415)493-6373
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS RET NEW BAL
__________ _____________ __________ __________ __________ __________ __________
BPERMFEE VALUATION 6,000.00 117.00 0.00 117.00 0.00
BE 41CRE VALUATION 6,000.00 0.60 0-00 0.60 0.00
T PERMIT 117.60 0.00 117.60 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ --------
CHECK 117.60 10206
------------
TOTAL RECEIPT 117.60
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
•