99080067 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION - PERMIT ExPIRAnoN
'
-REROOF PERMIT (408)777-3228 - PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN la)DAYS OF PERMIT ISSUANCE OR
fait DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS /
IRESIDENTIAL `' COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES C] g yes-I understand Nat a Class A
rn
NAME :Yoc- I ' ICCLe,- roof assembly is required.
rMye NO p Iridal I.C.B.o.a
ADDRESS 1 W� EXISTING ROOF COVERING
PHONE — /Y NUMBER OF EXISTING COVERINGS 51
CONTRACTOR'S^ �-1 '
/',,,,,r..._I CL4) Cer�l� T- 70 BE REMOVED TO BE RETAINED
NAME l�(1,1 lfC4, ll
ADDRESS 32 '7 �Phda,, Wye_
ING
clTv a ZIP J�- EXISTING
D�p
PHONE BUILT-UP ROOF
NUMBER ASPHALT SHINGLES - "❑/ �1
LICENSED CONTRACTORS DECLARATION
I hereby affirm then I am licensed under provekxu of Chapter a(commencing with Section WOOD SHAKES
_ 7000)of Myfslon 3 of the Business and Professions Code,ark my license Is In lull force and 1 "
affect. /1 1-C WOOD SHINGLES E]License Case C_3r, Uc.Number 211 VJ 2
�`Iq Couectar
Date 4 1
�ll� OTHER(SPECIFY)
fAUG
Opt from-BUILDER DECLARATIONPROPOSED 'hereby stens that I am exempt Iron are e: Anycity or cue Lew Ica the ideaslotowing neem.(Sec.]031.6,Buslnee entl PrdeeMws Coda: Arty city w wanly which repulse a permit to
construct,ener,lial dwriciah,or repair any structure,prior to la issuers,eao requires the BUILT-UP ROOF b0 1999applicant for such permit to Ne a signed statement met he is licensed pursuant a tiro provalomof the Contractors License LewChapter 9(commencing with Section 7000)of DMelw 3 of ins
Bus nese anti Profeeions Codes on that he la exempt therefrom and the bona Ion the alleged ASPHALT SHINGLexemption.Any violation d Section 7031.5 by any applkent for a permit subjects the applicant to e dyn penalty of wt more than Me hunareo oolaro(5500).):
01,as owner of the property,or my employees with wages as their ode compensation,will do WOOD SHAKES
the work,and the structure Is not intended or offered for sale(Sec.704.Business and Prole-
"improoveedtherion ands woo doessucchh License wwkniimmaetl or mroroual to an gh him ownOwner
of property
provided mwho toullds ei .WOOD SHINGLES ❑
such Improvements we net Intended on offereo for Bela.It,however,the building or Improvement
Is sod within one year of completion,the ownerbullderwill have the burden of proNng that he did OTHER(SPECIFY) ❑
net build or Improve for purpose of sale.). .
❑I,as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law does net 2J' PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bullde Or Improvm thereon,and who contracts for such projects
with a contrectorls)licensed pursuant to the Contractors Ucense Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B 8 P.C.for 0Yn sawn
owner Date
WORKERS COMPENSATION OECUAATION APPLICATION DATE VALUATION PERMIT FEE
'
I hereby affirm under penalty of perjury ane of the following declestlon:
❑1 have and will maintain a Gwilllcate of Consent to self-insure for Workers Compensation, p. Building
as provided for by Section 37W of the Labor Code,for the performance of the work ion which this 9--/Q C3 G �Q
Permit issued, r y��00
I�'(heve and will maintain Workers Compensallm Insurance,as required by Section 3700 of
Seismic r
the Lebon Code,for the performance of the work for which tNe permit Is Issued.My Worker's
Compares tlo Ineusnw cerrt tl Pdlcy number are: Total
Carhar �ZW00% �`� W Policy No. '�hr+ �al PER-Mg,,AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need net be completed H the permit Is for one hundred ddlero(S10o)or lee.)
any ppeerrson In rtify Harry mffenne ones foe to Via
aneeue;w to v e Wonthis ders'Compene"t Is Issued,itionall n
Laws oln6a% All roofs shall be inspected prior to any roofing material being
fema. installed. If a roof is installed without first obtaining an
Date ID Appmam I tt%6I l.I V r t ! inspection,I agree to remove all new materials for inspection.
NOTICE.fo APPLICANT:Com K,ono making the the
of Exemption,roe should become Applicant understands and will comply with all non point
select to Me Workers'Campena after
provolone of ire Lebon Code,you must(should comply
with such proAwons or this permit well be deemed revoked. Source regulations.
I certify III l have sad this applkatlon and state that the above Information is correct.l agree
to comply with all city and county Ordinances and state am
le relating to oul Ming construction,and All roof Coverings to be class"C"Or better.
hereby authorize representatives of the city to enter upon the above-mantloned property for In. /�s 1
specton purposes. &) ^� ,35'7-O/ �0 Gllpy��
(We)agree to nava,Indamnlly and keep harmless the City of Cupertino epeinst Ilabliftes, 0 rrr rr'
lu the gra,cosy and expenses which may In any way accrue against ee10 City In consequence
oluegrenu osis 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 APPROV ACCESS TO 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:35701007.00
1
INVOICE DATE.. . . . . : 08/10/1999
REFERENCE ID N ... : 99080067
SITE ADDRESS ..... : 10079 CARMEN RD
SUBDIVISION ...... .
CITY . . . ..........: CUPERTINO
IMPACT AREA ...... .
OWNER . . ..........: MCCUNE JOE B AND GLADYS L TRUS
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-2761
CONTRACTOR ....... : LIC #
COMPANY .......... :
ADDRESS ..........:
CITY/STATE/ZIP ... .
TELEPHONE ........ :
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPERMFEE P 157.00 0.00 157.00
BSEISMICRE P 1.00 0.00 1.00
158.00 0.00 159.00
ID --------DESCRIPTION VOICE ID - DESCRIPTION
......... ........ ...... ...............
5 FRAME 30] INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS