99080101 PERMrr.
APPLICATION FOR CITY OF CUPERTINO NUMBER
• INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406)T77-3228 PERMIT EX%RES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1K DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
TerrV 0Kl 1104q,0RESIDENTIAL COMMERCIAL OTHER
OWNER'S I - GV I&#"E I'4 o HAZARDOUS FIRE AREA
/1 YES ❑ If yes—I understand that a Class A
NAME 7 C r r✓�?Q root a .-I=Is required.
NO ❑ Initial- I.C.B.O.R
ADDRESS IL114 Carle de SeVl l EXISTING ROOF COVERING
PHONE � Z NUMBER OF EXISTING COVERINGS
.
CONTRACTOR'S n
NAME fIDRA -Id`y 111 Q, TO BE REMOVED TO BE RETAINED
ADDRESS /� n '
CITY&ZIP_��JS(� /S QA f 'Gat l� KAa
/� vtfder ¢ret K , xgsoo6 EXISTING ` C
PHONE "708 S95 -13U3 BUILT-UP ROOF •��jj 7Q,
LICENSE
NUMBER 74-70 ,11-9 ASPHALT SHINGLES /
LICENSED CONTRACTORS DECLARATION .,
I fnreby affirm that I am Ilcem ed under provisions of Chapter 9(cormtencing with Section WOOD SHAKES ❑
7000)of Division 3 of the Business and Professions Cade,and my license is in full force end
effect WOOD SHINGLES ❑
License Clew Uc.Number /4 /01 6
�,� C. f OTHER(SPECIFY)
Date qOWNER-BUILDER
/o Wry t • D h4 (Ia
theC* DECLARATION PROPOSED LS lUJ I�
hereby affirm that I am exempt from the e: Any ors License Lew for the requires
a g reason.
(Sec.7031.5,after,Improsa erect Professions or rep Code: Any city pr county which requires a permit to
con pplQntorsuch pmvw,demoto Me signed statny ement that
prior to Itslicense Issuance,also to
requires Me BUILT-UP ROOF AUG m3 1999
of the o for such permit is flaw w signed statement alai he it licensed pursuant to the pr 3 of me
of sin ss, a d Pro Ucertse Law(Chapter S(commenting with Section 7000)of DtWebn 3 til the
Business and Proasabna Sectio or that he Is exempt artfor a F and the basis for the alleged ASPHALT SHINGLE rK]-IC`
exemption.Artyf not one San five
7031.5 by any epdbant for a permit subjects the applicant to
e dull penalty of not more then lice hurWred collars($600).):OP Ry
01.as owner of the property,or my employees with wages an their We compensation,will do WOOD SHAKES
the waM.and the stradure Is not intended or offered lar sale(Sec.7044,Business and Prolan-
sane Ceds:'The Contnndo/sI-cense Law does not apply to an owner 0 property who toolds or WOOD SHINGLES
unproves thereon,and wino does such wo*himself or through his own employees,wooded that ❑
such Improiertwnis are not intended or offered for sale.It,howaer,the building or Improvement
Is said within one year of completion,the owner-buiaer will have the burden of proving that he did OTHER(SPECIFY) ❑
not Wild or Improve for purpose of sale.).
❑I,as owner of the property,em sxcluwncy contrecllrg with Ilcenmed contractors to construct
the pn yacl(Sm.70g1,Business and Professions Code:The Contractors License Law dealt not PROVIDE I.C.B.O.REPORT NO.
apply to an comer of property wtlo Wilds or immro sthereon,and who contracts for such projects
with a contractor(s)Ilcanaed pursuant to the Contractors Licems law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt untler Sac. ,B 8 P.C.for this reason
Owner oats APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perfury acre of the fdlowing dedemdon:
-11 have and will maintain a Carblicate of Consent to self-Insure for Workers Cormansatbn, Building
n provbetl far by Section 3700 of the Labor Cade,for the perlormence of the work for which this O^
pemtit isi and D D Seismic V
'fa have entl wilt maintain Worker's Compensation Insurance,as rmit i by$titian 3700 1� / Ip
th r Cotle,for the pedannarwe of the work for whidt this persalt i�JaeyW e
Compensatlen Inwurarwe carrier entl11Policy number are: / Total/ y i
carrier 'StA f" �uH A policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM YORKERS'
COMPENSATION INSURANCE bn neN.C{]
(This secied not be completed ne Il the persalt fe ler ohundred dollars(5100)or less.) "✓C ( (r
I comity that in the perks-mance of Ne work ldr which this pertMt Is bsuatl,I shell not employ
any pennon In any marrrer w as to become subject to the workers'Comperuation Lowe of Cell- All roofs shall be inspected prior to any roofing material being
femla. - installed. If a roof is installed without first obtaining an
Data Appacant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCAN. If,after maldrg this Certificate of Exemptlon,you mould become q IlCant understands and will
subject to the Workers'Compensatlon prarsbro of Ne Lebon Code,you must forthwith comply pp comply p y with all non point
with such provisions or this permit shell be deemed revoked. Source regulations.
I centlly that I have react this application entl elate that the above Information is correct.)agree
to comply with all city and county o murices entl state laws retailing to building commuctbn,she All roof coverings to be class 4or better.
hereby aulhorize representatives of this city to enter upon tine above-mentioned property for In-
spection purposes. p p
(We)agree to save,Intlamnity,and keep harmless the City W Cupertino against liabilities, O �//
D ib iN permit.en which they b ar7 way accrue against sea city b caneaquance SIGMA E OFA 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
of 1 BUILDING PERMIT RECEIPT OPERATOR: karenb
COPY q 1
Sec: Twp: Rug: Sub: Blk: Lot:37505016.00
DATE ISSUED...... . : 08/13/1999
RECEIPT q...... . . . : 9813
REFERENCE ID q . .. : 99080101
SITE ADDRESS .... . .
SUBDIVISION ...... .
CITY ... . . . . . . .... : CUPERTINO
IMPACT AREA ...... .
OWNER ... . . . . . ....: TERRY O'KEEFE
ADDRESS .. . . . . ....: 10440 CORTE DESEVILLE
CITY/STATE/ZIP ...: CUPERTINO, CA 95014
RECEIVED FROM ....: TIME
CONTRACTOR . . . ..... WRIGHT, LLOYD LIC q 20652
COMPANY .... . . ....: WRIGHT ANGLE CONSTRUCTION
ADDRESS .... . ...... 18356 BEAR CREEK RD
CITY/STATE/ZIP ...: BOULDERS CREEK, CA 95006
TELEPHONE .. . . . . . . : (408)395-1343
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
_ _____________ ---WWW---- __________ __________ _
BPERMFEE VALUATION 10,000.00, 157.00 0.00 157.00 0.00
BSEISMICRE VALUATION 10,000.00 1.00 0.00 1.00 0.00
010PERMIT 158.00 0.00 150.00 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ____________ __________________
CHECK 158.00 5474
------------
TOTAL RECEIPT 158.00
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
•
ACORD, CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDm)
07/13/99
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
' ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
NI NSURANCE, INC. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P. . BOX 809 COMPANIES AFFORDING COVERAGE
EL CERRITO, CA 94530-1916 COMPANY
A COMMERCIAL UNION INSURANCE COMPANY
INSURED COMPANY
EAGLE PIPELINE ' S B THE EMPLOYERS ' FIRE INSURANCE CO.
EARL INCE COMPANY
22622 San Vicente Avenue Q
San Jose, CA 95120 COMPANY
D
I ,
COVERAGES "
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE IMMIDDIYY) DATE(MMIDDM)
GENERAL LIABILITY GENERALAGGREGATE 52, 000, 000
X COMMERCIAL GENERAL LIABILITY PRODUCTS COMP/ PAGG 52, 000, 000
CLAIMS MADE a OCCUR PERSONALE ADV INJURY $1, 000, 000
A OWNER'S d CONTRACTOR'S PROT CALF28802 06/07/99 06/07/00 EACH OCCURRENCE $1, 000, 000
FIRE DAMAGE(Arry one lire) $100, 000
MED EXP(Arry ane Person) s5, 000
AUTOMOBILE LIABILITY
X ANY AUTO COMBINED SINGLE LIMIT 31, 000, 000
ALL OWNED AUTOS BODILY INJURY
(Per Pe n) $
SCHEDULED AUTOS
B ALL
AUTOS FAAA12448 06/07/99 06/07/00 BODILY INJURY
NON"OWNED AUTOS (Per acDEenD S
PROPERTY DAMAGE S
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY,
' EACHACCIDENT S
AGGREGATE S
EXCESS LIABILITY EACH OCCURRENCE S
UMBRELLA FORM AGGREGATE $
_ OTHER THAN UMBRELLA FORM $
ST - 5
WORKERS COMPENSATION AND TORYLAIMIT ER
EMPLOYERSLIABILITY
EL EACH ACCIDENT $
THE PROPRIETOR/ INCL EL DISEASE-POLICY LIMIT $
PARTNERSIEXECUTIVE
OFFICERSARE: EXCL EL DISEASE-EA EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONSR.00ATIONSIVEHILLES/SPECIAL ITEMS
CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED PER ATTACHED FORM
CG2010 .
10 DAY NOTICE OF CANCELLATION FOR NON-PAYMENT OF PREMIUM. -
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
. CUPERTINO SANITARY DISTRICT E�XPPIIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
20065 STEVENS CREEK BLVD. , BLDG.C 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
CUPERTINO, CA 95014 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON TME COMPANY, ITS AGER S OR REPRESENTATWES.
AUTHORIZED R PRESENTATIVE /C
I � G�l(.�2' l
ACORD ZO-5 IlIU31 0 ACORD C RPORATION 1988