99100151 APPLICATION FOR CITY OF CUPERTINO
INSPECTION DIVISION �Mff EXPIRATION
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IFWORK ISNOT STARTED
WITHIN 1 W DAYS OF PERMIT ISSUANCE OR
IN DAYS FROM IAST CALLED INSPECTION.
BUILDING ADDRESS
S
RESIDENTIAL L/ COMMERCIAL OTHER
OWNER'S HAZARDOUS FlRE AREA
YES ❑ If yes-I understand&of a Class A
NAME � roof assembi is required.
!/ Y� NO ❑ Initial LC.B.O.C
ADDRESSpOC4. y'or� %/r EXISTING ROOF COVERING
PHONE 2S 3 " -/O l0 S. NUMBER OF EXISTING COVERINGS -Opg�
CONTRACT 'S
NAME n G TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITY&ZIP v5gjS
//..'' pp EXISTING
PHONEI4'0V yys -� 7-1 BUILT-UP ROOF ❑
LICENSE �cj�3G•
NUMBER ASPHALT SHINGLES [}/
LICENSED CONTRACTORS DECIARATION
I hereby affirm that I am Ikamad under pronsome of Chapter a(commencing with Section WOOD SHAKES
7000)of Dfylslon 3 of the Business anc Professions Code,and my license Is In full force and
e11ec
ny WOOD SHINGLES // ❑
License Clew � � L Uc.'.Numbar �SS 6 -
�d�799 OTHER(SPECIFY) �]
Date -DUILDlef
OWNER-the G nt ho'.Ll N PROPOSED
hereby afll rm that am exempt from the Contractor's License Lew for the laeawag reason.
(Sec.]0315,Buelness ere Professions it any Any city or county which requires a permit ro
coollmotalter,Improve,demoto file signrepelrementructure,Ispoor to its(cense Issuance,talso odrapukaethe BUILT-UP ROOF ❑
of the
for such permit a Iiia a Coapt statement that he Is Ilse Section
pursuant to the provolone
el the ssContractor's o sense Lew(Chaplet h is ex encing withtherefrom
om and the b s for lonthe 3 of the F�N&_�_
'
Business entl y1olatim of Cotle)or that he k exempt therefrom end the baso for app icant td ASPHALT SHINGLES
a chit pen.Anyf not m n of than
len hundred
by arty applicant for a permit subjects ate applicant to
e cE3 penalty of not more than live by employees
yellers with
wage❑I,es owner of th cture i not I to ded oyeeeredfor see as their(SeI7 4,compensa nd Prlll0o WOOD SHAKES7 1999Na work,are Ne structure is not Intended or offered for sale(Sec.]014, roperty entl ProfBOr / JJJGene Cocle otham andw edoessuch Lawdi self apply ghhisco an ner efpoyeM whoided tat WOOD SHINGLESsuchn es thereon,entl who does deco work himself or .11,hoh ho own emhinge e,provend Netsuch Irtwithin oeyeere rel platin,oroametlfordao.IL however,the en of goi Ig Mat Ndil
is sold within one year of cemplellon,the owner-Wiltlarwlll hexa the Wrtlen al pvylnp that hada OTHER(SPECIFY)not Wild or Improve for purpose of dale.).❑I,as owner of Me property,am exclusively contraetirg with licensed comr9ctors to wrotruct the project(Sec.7044,Bueneas entl Professions Code:The Contractors Dcense Isw co ae rpt PROVIDE I.C.B.O.REPO
appy to an owner of property who bWtls or improves maroon,and who contracts for such projects
with a conveaor(s)licensed purwant to the Contractors Uce-se law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em wariest under Sec. ,B B P.C.for WS reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION q
I hereby affirm under penalty of perjury,one of the following declaration: Y V •o0
have and will minimal,aCerWkate of Consent to self-Insure for Workers Compensation, Building t/
' es rovltled for by Section 3]00 01 the Labor Code,for the performance of the work for which this
parmlt Is bsuec. / �' Q r
S81SmIC
�Q have and will mslntaln Workers Compensabon Inwmnoe,w;rewl red by Section 37W of
the"Labor Code,for the perlarrrance of the work for which this permit is lesood.My Workers I h
Comperwetlon Inwmnce carrier e�I"�'nu aware
Total t V
carrier-/'41 �'%Ctln ✓UNC- 'oM Poky No. 5S' 11 g>Z3gS�0O PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ -
(This section need not be completed it Ube permit Is for one hundrml colors($100)or 0".)
I cantly that In the perlormanoe of the work for which this permit is issued,I shall not amp"
any person In say manner so as to become subject to the WorkeJ conpeneatkn Laws w Call- All roofs shall be inspected prior to any roofing material being
forma. J � installed. If a roof Is Installed without first obtaining an
Date applkem yfys� inspection,I agree to remove all new materials for inspection.
subject too the Ww1,ws Conpemwkm pro,dANT: If,after sbna of the L this ate of abor Code,yyou mwt fortial cool Applicant understands and will comply with all non point
wan such proxnalons or this permit shall be deemed revoketl. source regulations.
1 minty that I have read this application and state that Ne above Information Is correct.)agree
to coney with all city and county ordinances and state[am relating to building conatructlon.are All roof cove 'ngst � eclass" or better.
hereby authorize representam a,of toe city to enter upon the ebwe-mentioned property Icr Irr
spathe,purposes.
(We)agree to save,'Inderni and keep h ureal the City of Cupertino agwhat liabilities,
ents,
judgmcanni ma
is aexpensed whiclr y In any way accrue agalnal said Cny In consequence
of me granting of this permit - SIG A R F ICANT 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 APPROVED ACCESSTO ROOF-SHALL BE'PROVIDED FOR INSPECTION
OFFICECOPY
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: karenb
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Sec: Twp: Rng: Sub: Blk: LoC:36924036.00
INVOICE DATE...... : 10/27/1999
REFERENCE ID # ... : 99100151
SITE ADDRESS .....: 6544 CLIFFORD DR
SUBDIVISION ...... .
CITY . . . . . . . ...... : CUPERTINO
IMPACT AREA . ..... .
OWNER .. . . . ....... : RODRIGUEZ HORACE AND LOUISE J
ADDRESS . . ........ :
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-4556
CONTRACTOR ....... : DADDARIO, STEVE LIC # 20739
COMPANY .......... : RENAISSANCE ROOFING CO INC
ADDRESS 2292 LINCOLN AVE
CITY/STATE/ZIP ... : SAN JOSE, CA 95125
' TELEPHONE ........ : (408)448-0697
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ ----_------
BPERMFEE P 107.00 0.00 107.00
BSEISMICRE P 0.50 0.00 0.50
--------- ------------ -----------
107.50 0.00 107.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
FRAME 307INSULATION
1 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
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