99080208 �. X30 -0 - 03 z_ 990 0
PERMIT R_
APPLICATION FOR CITY of CUPERTINO NUMBER "f
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 n '
lost 9 e e.,u �^+--
RESIDENTIAL COMMERCIAL OTHER
OWNER'S / „ HAZARDOUS FIRE AREA
/C.�. ^/.�.� YES ❑ Nes
y –I understand that- Class A
NAME roof as98rndys' required
r � NO ❑ Ird6al LC.B.O.A
ADDRESS S Q E: ' EXISTING ROOF COVERING
PHON& 6
/Q -IQS NUMBER OF EXISTING COVERINGS /
CO S '
' TO BE REMOVED TO BE RETAINED
NAME l �j
ADDRESS ` ///- YPE QF ROOF V I
CITY BZI r✓G�'�(�(/1'JICE EXISTING '
PHONa 5, p ''' 13 /J BUILT-UP ROOF ❑ �j
NUMBER 7 a a7OD ASPHALTSHINGLES ❑ ��/�
LICENSED CONTRACTORS DECLARATION
I hereby am.that I em Ilcareed under prwlalons of Chapter g(carnmencing with Section WOOD SHAKES
]000)of Dryean 3 of the Buelness and Profneona Code,and my license Is In lull brae and
ellen' ,{ry WOOD SHINGLES ❑
LicenseCla iNumber `c 74"99 10,�/ r ElDateL Cont tor OTHER(SPECIFY)
OWNER-BUILDER DECIARAMN PROPOSED
1 hereby affirm that I am exempt from the Con"clor's License taw for the following reeeon.
(Sec.7031.5,Burliness and Professions Code: Arty dry or county whirr requires a penntt to
construct,after,Improve,demolleh,or repair arty structure,prior to Its issuance,alta requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he Is Ilcana cl pursuant to he prwlslons �,
of he Corral Ulcerate Law(Chapter B(commencing with Section 7000)of Olvelon 3 of the O C`aUT/—
Buslneas and Professions Code)Or Mat he Is exempt therefrom and the Peels for the alleged ASPHALT SHINGLES q
exemption.Any violation of Section 7031.5 by arty applicant for a permit subjects Me applicant to II 3 Q l� �I'
e civil penalty of not more then We hundred dollars(5500).): O �� 1„'19
❑I,as owner of the papery,« em WOOD SHAKES
my employees wegea as Bode entld will . ❑
dna work,errd ha atrucWre Is not Intended or offeretl for Bab(Sec.]614,Buslnaea erq Prolee� - ' t�V
Bions Code:.The Contractors Ucense Law does rot apply to an owner of property who ulltle or WOOD SHINGLES--------.
Improves thereon,and who does such work himself or through his awn employees,provideal Met
such Improvements,are not Intended o;offered for sale.If,however,the building or Improvement Jf 0 C d
Is add within ane year of completion,the ownerbulloer will hero the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of Bele.). ,
❑I,all owner of the property,am aaclusWy,contracting with licensed contractors to construct
He project(Sec.7014,Business and Professions Code:The Contrawoes Licanee Law does Trot PROVIDE I.C.B.O.REPORT NO.
appy in an owner of property who bulltl,or lm roves Hereon,and who contracts for such projects
with a contraclor(s)licensed pursuant to the CFonbactore Uceme Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sac. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
\ WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of penury one of he fallowing declaration: 0�
❑1 halo and w0 maintain a Certificate of Consent to se8anaure for Worker,Compensation, Building A, ,,
as prWdsd for by Section 3700 of the tabor Cade,for the performance of the work for which this Q OM
per Is Issued. `
hero and will maintain Workers Compensation Insurance,all required by Section 3700 of Seismic
00
I Labor Code,for the performance of the work for which this permit Is Issued.My Workers ,
- mpeneet�bn I�n����/¢cerrl�ej/$JC�Polly mbar ere: < Total
Ce"is, /Se(,i / ��� PdlryNo.1571 //� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CO
(This section need not be completed If the permit Is for one hundred dollars($100)or lees.) CI
I comity that In the performance of the work for which this permit is Issued,I&ell rat employ
any person Ina manner w all to became subject to the war or mpeneatlo wt of call- All roof^shall be inspected prior to any roofing material being
fornix. - installed: If a roof is installed without first obtaining an
Date L`�9 Applicant inspection:I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: II,aver making the Certificate r xemptlon,you ahoukl become Applicant understands and will comply with all non int
subject to the Workers'Companeauon prwielons of he Labor e,you must forthwith comply pP P Y
with such provltlons or this permit shalgbe deemed ravcked. source regulations.
I cardy Mat I have react this application and state that the some Information Is correct.I agree
to campy with all city and county ordinances and state laws relating to bunting combustion,and All roof crovQrin be class f-kr better A
hereby euua repreeentelivee off this Mia city to enter upon the above—mentioned property for In. /�s// ,�•!,//�
epaclbPurposes.
rpoaee.
(We)agree to save,indemnify and keep harmless Me City of Cupertino against lubim".
jutlOmenm,costs and expenses which may In any way accrue against sold Gry In consequence
ofthegentIng ofthis permit. SIGNATURE O 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 APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
CITY OF CUPERTINO
Ite 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: nancyc
COPY N 1
Sec: TWp: Rng: Sub: Blk: Loe:36909032.00
DATE ISSUED. . . ....: 00/30/1999
RECEIPT p. . . . . . ... : 9926
REFERENCE ID # ... : 99000200
SITE ADDRESS . . ...: 10298 COLD HARBOR AV
SUBDIVISION . . . ... .
CITY .... . . . . . . ... : CUPERTINO
IMPACT AREA . . . . . ..
OWNER .... . . . . . . .. : WEST PAUL E AND SCHWARTZ-WEST
ADDRESS . . . . . . .. .. :
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-3328
RECEIVED FROM .... : TIM
CONTRACTOR . ...... : COSMOS, RICHARD LIC N 18844
COMPANY . . . . ......: COSMOS ROOFING
ADDRESS . . . . . ..... : 450 SAN ANTONIO RD
CITY/STATE/ZIP ... : PALO ALTO, CA 94306
TELEPHONE . . ...... : (415)493-6373
FEE ID OMIT QUANTITY AMOUNT PD-TO-DT TNIS RED NEW BAL
---------- ------------- """------ ---------- ---------- ---------- ----------
BPERMFEE VALUATION 10,000.00 157.00 0.00 157.00 0.00
B0MICRE VALUATION 10,000.00 1.00 0.00 1.00 0.00
T PERMIT 158.00 0.00 158.00 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 158.00 10177
------------
TOTAL RECEIPT 15B.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ...-a....................... ........ ............................
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
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