99090160(-r) o 0 d9 4b I 0
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R"
INSPECTION DIVISION PERMIT cPl n it
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
- _ WITHIN 190 DAYS OF PERMIT ISSUANCE OR
01st C42VCe2 4.
NAME
ADDRESS /3O ( S. M A✓G f+ /or .S VA1.� 4Vvb�
PHONF 3 G•a-4� .
NAMEAffSt
ADDRESS Po 96�
CITU d ZIP /� 7b b
PHONELICENSE
NUMBER. �� !S3
I hereby affirm that I em licensed under provisfom of Chapter 9 (commencing with Section
7(y00)'of DMalan 3 of the Business and Professions Code, and my license Is In full force end
enact. to9
Dcerue Clens Lia Number I r r
Date 9 -aa .9 Connector Ilk
^6 — , ^ I � �
OWNER -BUILDER DECLARAT10N
I hereby affirm Met.I am exempt from the ContraGor's License Law for Ma following reason.
(Sec. 7031.5, Business and Professions Code: Any city on county which requires a pennant to
construct, alter, Improve, demolish, or repair any structure, prior to Its leeuence, alto fact the
applicant for such parmnt to file a signed statement that he Is Irceneed pu reuant to the provision
of the Contractor's License Law (Chapter 9 (commenting with Section 7000) of DHisbn 3 0r' Me
Business and Professions Code) or that he is exempt therefrom and Me bade for the alleged
exemption. Any vitiation of Section 7011.5 by any applicant for a permit subjects the applicant to
a cMl penally of not rcre Than five hundred dollars 15600)J:
❑ I, as owner of the property, or my employam with wages as Meir sole companmtbn, will do
Me wwk, and the structure Is not Intended or offered for sale (Sec. 704.1, Business and Prates -
dons Cade: The Contractor', License Lew does not apply to an owner of property who builds or
knproves thereon, end who does suit work htrnati or Mrough his earn employees, provided Mat
such Imprmemants are not Intended or offered for sale. If, however, Me building or Improvement
Is sold within one year of completion, the owner -bulkier will hate Me burden of proving that he cud
not build or Improve for purpose of sale.).
❑ I, as owner of the property, em exclusha ty contracting with licensed contractors to construct
the pMmt (Sec. 7044, Business and Professions Code: The Contractor's License Lew dose nut
apply to an owner of property who buifoa or Improves thereon, and who contracts for such prejectn
with a contractor(s) licensed to tenant to Me Conirador'9 License Lew.
❑ I em exempt under Sec. ,B d P. C. for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one, of the Idiowing declaration:
I have and will maintain a Certificate of Cohmen to self -Insure for Woftea Compensation,
n provided for by Section 3700 of the Labor Code, for Me performance of the wore for which the
per t Is issued.
PDX
have and will maintain Workers Compensation Insurance, as required by Section 3700 of
1 s Labor Code, for Me performance of Me work for which thle permit Is Issued. My Workers
�Compereatfon Insurerce cayrr�ier end F'b'\\llry number ere: /� ,r�
Carrier '�arE Fu U Policy Nd'' o f0(J Z2 �!
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CL]
(This motion need not be completed N the peep is for ane hundred dollars ($1 DO) at lase.)
I cerbly that F the pedormance of the work for which this pen -mit Is leeued, I Mail not employ
any person In any manner to m to become sub}act to Me Workers' Compensation Laws of Call-
fornla.
Date Applicant
NOTICE TO APPLICANT: If, after maklmig this Certificate of Exemption, you Mould become
subject to the WoMen, Compensation provisions of the Labor Code, you mud forthwith comply
with such provisions onthis permit shal9be deemed revoked.
I certify, Met I Neve read this application end state that the above Mfonnauon is correct. I agree
to comply with all city and county ordinances and state laws elating to bulk" construction, and
hereby authorize reprmentprm a of Mie dry to enter upon the above rtwnllaned property for In.
specUsn purpose¢.
(We) agree to save, Indemnity and keep harmless the City of Cupertino against Ilabllltlee,
Judgments, costs and expenses which may In any way accrue against mid City In consequence
PRE -INSPECTION:
INSP.
TEAR OFF INSPEC
PLYWOOD:
RESIDENTIAL X COMMERCIAL OTHER
VES ❑ B yes - I Inderstand Rtel a Class A
rod ara4urtdy Ls requtred.
NO ❑ trYYal I.C.B.O.
NUMBER OF EXISTING COVERINGS
TO BE
TO BE
TYPE OF ROOF COVERING
EXISTING,
BUILT-UP ROOF _
ASPHALT SHINGLES A!)r(❑ I I
WOOD SHAKES
VALUATION
PERMIT FEE
/t7
WOOD SHINGLES
Building q7 .
OTHER (SPECIFY)
PROPOSED
ILP_
BUILT-UP ROOF
_
ASPHALT SHINGLES
0
WOOD SHAKES
❑
WOOD SHINGLES
❑
OTHER (SPECIFY)
❑
PROVIDE I.C.B.O. REPORT NO
PROVIDE MFGR. INSTALLATION SPECS
APPLICATION DATE
VALUATION
PERMIT FEE
Building q7 .
/�v/fU 6✓
Seismic 5�
/
Total CL1__<(Z
I PERMIT AUTHORIZATION I DATE I
-�-� I �- -) y ?91
All roots shall be inspected prior to any rooting material being
installed. If a roof is installed without first obtaining an
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
source regulations.
All roof coverings t ss 'C` or better.
,d/1C1rn �ruzna 9-ant-9�
OF. APPLICANT DATE'
IN -PROGRESS:
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: chriatye
Sec: Twp: R g: Sub: Elk: Lot:37535003.00
INVOICE DATE......: 09/28/1999
REFERENCE ID # ...: 99090160
SITE ADDRESS .....: 10731 CARVER DRIVE
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: EARL
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
CONTRACTOR .......: RAINIEREI, ANTHONY LIC k 20506
COMPANY ..........: ANTHONY ROOF SERVICE
ADDRESS ..........: 1655 FORMAN AVE
CITY/STATE/ZIP ...: SAN JOSE, CA 95124
TELEPHONE ........: (408)265-5147
FEE DESCRIPTION CHK
--------------- ---
BPERMFEE P
BSEISMICRE P
yr IDDESCRIPTION
-------------------
FRAME
601 ROOF TEAR OFF
603 ROOF BATTENS
•
TOTAL FEE
PAID -TO -DATE
BALANCE DUE
97
00
0.00
97.00
0.50
0.00
0.50
97
50
0.00
97.50
VOICE ID
DESCRIPTION
307 INSULATION .
602 ROOF PLYWOOD NAIL
604 ROOF IN -PROGRESS
CITY OF CUPERTINO
• 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: chrletya
COPY 4 : 1
Sec: Tp: Rng: Sub: Blk: Lot:37535003.00
DATE ISSUED.......: 09/28/1999
RECEIPT H.........: 10162
REFERENCE ID k .: 99090160
SITE ADDRESS .....: 10731 CARVER DRIVE
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: EARL
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....:
TIM
CONTRACTOR .......:
RAINIEREI, ANTHONY LIC # 20506
COMPANY ..........:
ANTHONY ROOF SERVICE
ADDRESS ..........:
1655 FORMAN AVE
CITY/STATE/ZIP ...:
SAN JOSE, CA 95124
TELEPHONE ........:
(408)265-5147
FEE ID UNIT QUANTITY
AMOUNT PD -TO -DT THIS REC
NEW SAL
---------- ------------- ----------
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
PERMIT :
97.50 O 00 97.50
0.00
METHOD OF PAYMENT AMOUNT
NUMBER
----------------- ------------
CHECK 97.50
------------------
7394
------------
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
0