99090067 ., 357- o ! - OYz" �gogodb�
PERMIT'
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT . . (408) 7'77-3M PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
-
RESIDENTIAL &—COMMERCIAL OTHER
OWNER'S - HAZARDOUS FIRE AREA
�p� YES ❑ If yes-I understand that a Class A
NAME�r—'�""1- _ �R..r �• root assembly is required. .
L r NO ❑ Initial I.C.B.O.B
ADDRESS-
/ EXISTING ROOF COVERING
PHONE Y 7�L5 —/Z2-3 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
TO BE REMOVED - 0 BE RETAINED _
NAME
ADDRESS lel TYPEIOR ROOF^COVERIIJG
CITY&ZIP �, W - /•� I V
EXISTINGh SEP - 9199
PHONR !� 6 err-��O V _ BUILT-UP ROOF U ❑
LICENSE
NUMBER (�J/ 5 73 ASPHALT SHINGLES/.
LICENSED CONTRACTORS DECLARATION /
I hereby affirm that I am llcaneed under provisims of Chapter S(commencing with Section WOOD SHAKES
7000)of DNislon 3 of the Bunnese and Promselons Code,and my license Is In full torte and
°H°I y 9 / WOOD SHINGLES El
License Class C' ✓ • Ul Number
'Date 9 " 2y Contractor r P ❑
OW from BUILDER Dtors Uk TI
hereby eHlrm that I am exempt from tow Cwimnore Lkensa Lew lar the Iolbwirhg
(Sec.7031.5,Business and!Professions Cade: Any city or wunry which requires e
Miss
construct,after,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the I ❑
eppllwni for such permit to Ills a elpnetl statement that he ls licensed pursuant to the provld
n the Canireaore Ucanee Law(Chapter B(commencing with Section 7000)of ONlslon 3 of
.
Business and Pmisselona Cotle)or that he is exempt therefrom erhd the heal°for the all ❑
exemption.Any violation of Sectlon 7031.5 by any applk°nl W a permit subjects the applican
e civil penalty of not more than five hundred callers($51 ll--ll
1,as owner ofsthe ruchu 915 not y,or
tendedrry ayeeered for" fts a
7 sole wmpenAm
the work,end the elructure le not Intentletl or offered ror sale(Sec.7044,sashesskus Code: The ContZoes License Law does not apply to en owner of propertyImproves thereon,e+M who tlwe such work hllneeff or Uhrouph hoe own errpbyaaeeach Improverthenis ere rwi Intandetl or offered loft Bele.I(however,the bulltllnp ,
Is to within one year of completion,the owner-bullder All have the burden of proving that he did OTHERSPECTM
not build or Improve for purpose of°ale.).' (SPECIFY)
Me0projeecct(Sam.70ner of"pBwsinesss,anny,am d PrufessllonewCode The CmbenoeLicense Law doeconsbruct
rut PROVIDE I.C.B.O.REPORT NO.��
applyto an owner of property who bund°or Impraves thereon,and who cora a for such projects
with a convector(s)Iicensec Pursuant to the Convenor'°ucanx Law. PROVIDE MFGR. INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 6 P.C.for this reason
owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration: -7 _
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compern eUon, Building
as providetl for by Section 3700 of the Leber Cade,for the performance of the work for which this 9 Q
pe" Ia issued. / F/L � /J , �� Seismic
have and w111 maintain Workers Compensation Insur once,as rmulrec by Section 37DD of
the or Cotler for the performance of the work loft which iris permit Is Issued.My Workers
Comparmsibnlns� carder rd Poo number are: �ji� - Total )
Carder "2 _7� Poll No. "`o-�-17_/b/.7 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.I]
(This section need rot be wmpletec If the penal Is for we hundred dollars(5100)aft less.)
I cart"y,that In the performance of the work lar which this permit to same,I shell rot empkry
any person In try manner so as to became subject to the Workers'Compensatlw Lawn of Cell- All roofs shall be inspected prior to any roofing material being
•rornla. installed. If a roof is installed without first obtaining an
Dina 4 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE I1To AAPIPU . If,after making this CoiUl M1ite of Exemption,you Mould become
eua
onpeneaton provisions of the Labor Code,you must forthwith compy Applicant understands and will comply with all non point
with such provlslons or this permit ahall W tleame f revoked. source regulations.
. I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county orlinancas"state laws fasting to bullring construction,and All roof coverings to be class"C"or Metter.
hereby full representatives of This city to enter hpw Ina above-mentorwtl property for In. /[// /^1 9/p �/Q
e. cilmWe) purpoeae. LJ / ! 1 • /
(Wm)agree to Baro,Indemnify and keep hertnless the City of Cupardna a Inst Ilabllitlss,
. of=gnal,wet°arca expenses which they In anyway accrue against ultl Clry�n coneequernce SIGNATURE F APPLICANT DA E
of the renting of I ne expenses
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 INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE -
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: chri5tya
Sec: Twp: Rug: Sub: Blk: Lot:35701042.00
INVOICE DATE. . ....: 09/09/1999
REFERENCE ID k ...: 99090067
SITE ADDRESS .....: 10189 CASS PL
SUBDIVISION .. .. ...
CITY .... . . . . . . ...: CUPERTINO
IMPACT AREA . ......
OWNER ...... ......: BUFFALOW HENRY JR AND SUSAN
ADDRESS ..... . . . . .:
CITY/STATE/ZIP . . .: CUPERTINO CA, CA 95019-2751
CONTRACTOR . ......: LIC #
COMPANY ... . . . ....:
ADDRESS .. . . . .....:
CITY/STATE/ZIP .... ,
TELEPHONE . . . .....:
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPERMFEE P 197.00 0.00 197.00
BSEISMICRE P 1.90 0.00 1.90
--------- ------------ -----------
198.90 0.00 198.90
ID ------- DESCRIPTION VOICE VOICE ID -----_. --SCRIPTION
........ .................
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 609 ROOF IN-PROGRESS
•
_ CITY OF CUPERTINO
1 Of 1 BUILDING PERMIT RECEIPT OPERATOR: chriStya
COPY N 1
Sec: Twp: Rng: Sub: Blk: Lot:35701042.00
DATE ISSUED....... : 09/09/1999
RECEIPT #......... : 10029
REFERENCE ID # ... : 99090067
SITE ADDRESS .....: 10189 CASS PL
SUBDIVISION ..
CITY CUPERTINO
IMPACT AREA ...... . -
OWNER . ........... : BUFFALOW HENRY SR AND SUSAN
ADDRESS .......... :
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-2751
RECEIVED FROM .... : TIM
CONTRACTOR ....... : LIC N
COMPANY .......... :
ADDRESS .......... :
CITY/STATE/ZIP ... .
TELEPHONE ........ :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW DAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 14,000.00 197.00 0.00 197.00 0.00
BSE SMICRE VALUATION 14,000.00 1.40 0.00 1.40 0.00
1i PERMIT 19B.40 0.00 198.40 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 198.40 10230
TOTAL RECEIPT 198.40
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
•