99100094 q —I(UD�9 PER
APPLICATION FOR CITY OF CUPERTINO N
INSPECTION DIVISION PERMITEXPIRATION
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1W DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION,
2a,81 - RESIDENTIAL___L/COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
NAME /1_"1,A 1 � .VES ❑ r yes—I endersrequired. class A
root essentially is repaired.
NO ❑ INtial LC.B.O.N
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME ��✓4.t17-Ay/ e641A)G /ICo : - SZZAIf TO BE REMOVED TO BE RETAINED
ADDRESS r /� �� TYPE IN
cITY a ZIP / 0 5" 6/. (Sf_ G1�1 .� Cv�
EXISTING
PHONE f/6X 2L '� - g S BUILT-UP ROOF !� fj]�/G, e
LICENSE / 4
NUMBER (�. d"/L ) ASPHALT SHINGLES 9
UCENSED CONTRACTORS DECLARATION 7
I hereby affirm Met I am licensed under provisions of Chapter B(commencing wtih Section WOOD SHAKES
7000)of Dwalon 3 of the Business and Professions Code,and my license Is In full force antl
Olson.
WOOD SHINGLES ❑
License Class Le.Number/ !U% <
Contractor
(SPECIFY)
Date contract
• OMER-BUILDER DECLARATION PROPOSED lay
I hereby affirm Met I em exempt tram the Contractors License Lew for Ne followMg reason.(Sec.7031.5.Business end Professions Coag: Ary dty or county whldr requires a Permit to
construct,after,improve,demolish,or repair any structure,prior to Ile Issuance,also requires Me BUILT-UP ROOF OCT 091999applicant for euenpermti to file a signetl statement that he fs licensed pursuant to the provisions
of the Contractors Ucenee Law(Chapter 0(commencing with Section 7000)of DMeion 3 of the
Business and Professions Code)or that he le exempt therefrom antl the basis for the alleged ASPHALT SHINGLEexempt I to S ] e a licant fora rmil sublecis rite applicant to dvllp r all
❑I, ansetionId00 WOOD SHAKES
the oro r e ss and Protas-
alone a or who builesor WOOD SHINGLES ❑ '
Improves
ft�hlm�ffortrrFhlb awn em proWtletl thatU Imprhis lding or Improvement
iseaavof yea pie fproving ttwrnaaitl OTHER(SPECIFY) ❑not build or❑1,as ro ntmctors to construct
Me pr m errtl Prolevalona Catl$a.
ucenae Law does sat PROVIDE LC.B.O.REPORT NO,
appy or for such pro)ects
p" t PROVIDE MFGR.INSTALLATION SPECS.
m & Mr Mie reason
Owner ata APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have est will meinmin a Certlficato of Consent to self-Insure for Worker's Compensation, / O 1.7 BUIIChn
m pro+ead far by Section 3700 of Me Labor Code,for the perfomaIN work
performance of ifar which this (Q//p al %s &o g
rmit
peis Issued. ( /
01 have and will maintain Workers Compensation insurance,as required by Stolon 3700 of Seismic
IN Labor Code,for the performerca of the work for which this permit is issued.My Workara Total
Compensation Insurance callare Policy aPolicy number are:
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C[] /z
(This section need not be completed It the permit is for one hundred dollars($1 W)or lose.) 7
I catty that in Me performance of the work for which this permit is Issued,I shall not empey- '
any person in any manner so ae to become subject tca workers'Compensation Lawn of Call- All roofs shat be inspected prior to any roofing material being
tme' installed. If a root is installed without first obtaining an
Do Ad
Ad _ inspection,I agree to remove all new materials for inspection.
. tion E APPLICANT: IL after m f ption,you ahodd bemnre Applicant understands end will comply with all non
subject to the Workers'Compensation provisions of Me Labor Code,you must forthwith comply PP p y point
wild such proWsions or this permit shall be deemed revoked. Source regulatl0 S. _
I certify Mat I have read this application and state that Me obeys Information Is correct I agree
to comply with an city and county ordinances and state leve relating to bulldlag cormInuctbq and All r00}COVerI St0 b0 Cl SIS ever.
t areby authorize rapraeenMUvea of this city to enter upon fire above-menfiored property ion in.
d
speion purposes.
(We)agree to save,inclarmi and keep harm Me City of Cupertino against liabilities, - (0
Judgments,coals and expenses which may In any way eccfupagainst send City In consequence
AOL of IN granting of this permit. - SIG F APPLICA D E
PRE-INSPECTION: PLYWOOD: IN-PROGRESS: r
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
OFFICE'll
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: nancyc
Sec: Twp: Rng: Sub: Blk: Loe:32630185.00
INVOICE DATE...... : 10/19/1999
REFERENCE ID # ... : 99100094
SITE ADDRESS . . . ..: 20813 ELENDA DR
SUBDIVISION . . . . ..:
CITY . ..... . . . . . . .: CUPERTINO
IMPACT AREA . . . . . ..
OWNER ...... .. . . . . : FLAVIN PATRICK AND KATHLEEN V
ADDRESS ..... . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014
CONTRACTOR .. . . . .. : LIC b
COMPANY .... . . . . .. :
ADDRESS ... . . . . ...:
CITY/STATE/ZIP ....
TELEPHONE . . . . . ....
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
_______________ ___ _________ ------------ ___________
BPERMFEE P 207.00 0.00 207.00
BSEISMICRE P 1.50 0.00 1.50
_________ ____________ ___________
208.50 0.00 208.50
VID --------DESCRIPTION----_---- VOICE ID .---..- DESCRIPTION
.
........ ..............
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•