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99100013 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R- REROOF PERMIT INSPECTION DIVISION PERMITEXPIRATION (40$)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS Z a(� ,4� RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA YES ❑ M yes—I understand that a Class A NAME roof assembly is required. Initial I.C.B.O.if ADDRESS 00/72 7_ EXISTING ROOF COVERING kt PHONEl NUMBER OF EXISTING COVERINGS CONTRACTOR'S/ /11 NAME L i TO BE REMOVED TO BE RETAINED ADDRESSn D O Qz /�� c � - TYPE OF ROOF COVERING rvazlP c� EXISTING -- —. PHONE BUILT-UP ROOF - 1 Lr—Q u UCENSE NUMBER ASPHALTSHINGLE �U OCT ❑ 99 U U NSEDCONTRACTORS DECLARATION I hereby affirm that I am licensed under provisioner of Chapter 8(commendrg with Section WOOD SHAKES 7000)of Divfslon 3 of the Business and Professions Code,and my license is in lull torte and effect. WOOD SHINGLES By Ucense Claw Us.Number Date `ly?' COnlnaalOn OTHER(SPECIFY) OWNER-BUILDER DECLARATION PROPOSED I hereby affirm Met I am exempt from the Conlractofe License Lew for the bliowlng reason. (Sec.7031.5,Business and Profeeslors Code: Any city or county which requires a permit to construct,alter,improve,demolish,or repair any structure,prior to its issuancealso requires the BUILT-UP ROOF El for such permit to file a signed statement Mel he Is licensed pumunni to the provisions of the Contractors Usti Lew(Chapter B(commencing with Section 7000)of DNlslon 3 of the Business and Professions Cade)or that he Is exempt therefrom and the basis for the allegedASPHALT SHINGLES J��'.[l� exemption.Any vanatlon of Secdon 7031.5 by any applicant for a permit subjects the sail to ;/'—' e dol penalty of net more Men Irve hundred dollars($500).): C]1,as owner of the property,or my employees with wages as Meir We compensaUan,will do WOOD SHAKES ❑ OZ� the work,and the structure Is not Intended or offered for auto(Sac.7044,Business,and Pmfes. cions Coder The Contractors Ucenss Law does not apply to an owner of property who bul ca or WOOD SHINGLES Improves thereon,and who does such work himself or through his awn employees,provided Mat ❑ such Improvements are net intended or offered for sale.If,however;the building or Improvement is sold will one year of completion.the owner-builder win have the burden of proving Oat f d do OTHER(SPECIFY) El build or improve 1n purposeala.I. of s ❑1,as owner of the property,am exclusively conVeaingg with lkeneed contractors nslr to coucl the project(Sea.7044,Business and Prolewors Code:Tha Contractors Ucenme Law does rpt PROVIDE I.C.B.O.REPORT NO. apply,to en minor of property who builds or improves thereon,and who contracts for such projects ' with a contractogs)Ilcenced pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑I am exempt under Sec. a&P.C.for this reason Owner _ Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury ane of the fallowing declamnon: ❑ 7. ' I have and will maintain a Certificate of Consent to s,eff-Insure for Workers Compensation, Building as,provided for by Section 37W of the Labor Code,for Me perormeneo of the work for which this a mu •y'O ^ , permit is Issued. /) i V 0 pihave and will Imtain Warkerb Cwrpense0an insurance,as required by Section 3700 of "D' �' Seismic Me Labor Code,for perarmence at this h this permit u issued.My Workers Conmanaadon n co carrier and Policy nu r . /1 �yr• •�, Total / Carrier ✓� 4r7 CrC Loy No.5 //�Qz/� N /r! ERMIT AU O ZATIO DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C{] (Irks section read rwl be completed it Me permit Is for one hundred dollars($100)or lase.) T 7 I cerdfy Mat In the performance of the work for which this permit Is Issued,I shall not employ arty Person In any manner so as to become subject to the Workers'Compensation Laws of Cell- All roofs all be inspected prior to any roofing material being forms.foa. instal d. If A roof is installed without first obtaining an Date Applicant i tion,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making this Cedficale of Exemption,you should become licant understands and will comply with all non point subject to the Worlam'Compensation provudons of the Labor Cade,you must brthwlb comply PP P Y P with such provisions or tree permit ii be deemed revoked. CfF ns. I certly that I have read thus application and state that the above Inbrmetbn le wmect. agree to comply with all clty and county ordinances and state laws retailing to building construction,antl s t0 be class"O'Of better. hereby authorize representatives of this city to enter upon the above mentioned property for In- spection purposes. - ✓ g (We)agree to save,Indemnity and keep harmless the City of Cupertine against Ilabllitiet. U' 1�" Judgments,costs and expenses which may in any way accrue against mid City In cnnsequenee of the granting of this permit DATE PRE-INSPECTION: PLYWOOD: IN PRO SS: - INSP. DATE INSP. DATE IN P. DATE TEAR OFF INSPECTION: BATTENS: 'FIN \ INSP. DATE INSP. DATE INSP. DATE 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: chrletye Sec: TwP: Rng: Sub: Blk: Lot:35618044.00 INVOICE DATE...... : 10/04/1999 REFERENCE IO # ... : 99100013 SITE ADDRESS ..... : .21722 COLUMBUS AV SUBDIVISION ...... . c� CITY ............ . : CUPERTINO IMPACT AREA ...... . OWNER . ........... : LEIRNESS PHILIP H AND CAROLYN ADDRESS .......... : CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-4713 CONTRACTOR ....... : DADDARIO, STEVE LIC H 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, 147.00 0.00 147.00 BSEISMICRE P 0.90 0.00 0.90 --------- ------------ ----------- 147.90 0.00 147.90 VIO e.... DESCRIPTION-__----.. VOICE ID -.-__-_DESCRIPTION .. .� ........ .............. 305 FRAME 307 INSULATION 601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 603 ROOF BATTENS 604 ROOF IN-PROGRESS i �EV s • ' CITY OF CUPERTINO 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: christya COPY N 1 Sec: Twp: Rng: Sub: Blk: Lot:35618044.00 DATE ISSUED....... : 10/04/1999 RECEIPT q......... : 10238 REFERENCE ID N ... : 99100013 SITE ADDRESS ..... : 21722 COLUMBUS AV SUBDIVISION ...... . CITY ............. : CUPERTINO . IMPACT AREA ...... . , OWNER ............ : LEIRNESS PHILIP H AND CAROLYN ADDRESS .......... : CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-4713 RECEIVED FROM .. . . : JOSE CONTRACTOR .... . . . : DADDARIO, STEVE LIC N 20739 COMPANY ...... . . . . : RENAISSANCE ROOFING CO INC ADDRESS ....... . . . : 2292 LINCOLN AVE CITY/STATE/ZIP . . . : SAN JOSE, CA 95125 TELEPHONE ...... . . : 14081448-0697 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- BPERMFEE VALUATION 9,000.00 147.00 0.00 147.00 0.00 BS�MICRE VALUATION 9,000.00 0.90 0.00 0.50 0.40 Tl PERMIT ----147 90 0.00 147.50 ------0 40 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ ------------------ CHECK 147.50 16217 • TOTAL RECEIPT 147.50 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 •