99080162 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R-
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(406)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1110 DAYS OF PERMIT ISSUANCE OR
' 1110 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS {x �iO�jT2 �� i/tL �C�/
t• RESIDENTIAL,.----- COMMERCIAL OTHER
OWNER'S /,, _' HAZARDOUS FIRE AREA
NAME Ol fJZo L. YES ❑ I�—Itkbly isandttlet9ClassA
essemMy a required.
- NO ❑ Inifil LC.B.O.C
ADDRESS /OSSU' I05Sy �kl. r' c4 l I Z>I.VP ..EXISTING ROOF COVERING
PHONE
NUMBER OF EXISTING COVERINGS
CONTRACTORS
NAME
, TO BE REMOVED TO BEaEINED
ADDRESS �� 2-6-3•: - �£ _ / I C.*- TYPE OF ROOF
aTvazlP f�l� W K r" EXISTING
PHONE 2-52^ 612—(' BUILT-UP ROOF ;gZ/4T
LICENSE
NUMBER �'1. D.g ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECIMATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with SeGion WOOD SHAKES
]000)of Division 3 of the Business and Professions Code,and my license b In lull force and
offect.
Z0 WOOD SHINGLES ❑
Lkerrse Cie ^ -x tic.Number
Date 2- g crest a' � OTHER(SPECIM ❑
OWNER-BUILDECLADERATIO PROPOSED
I hereby affirm that I em exempt from the Contractor's License Law for the Mllowlng reason.
(Sec.7031.5,Business and Professions Cade: Any city or county which requires a permit to
construct,after,Improve,demolish.or repair any structure,prior to Its leeuaro .also requires the BUILT-UP•ROOF ❑
applicant for each pemYl to its a signed statement that he is licensed pursuant to Me provisions
of the Contractees Uccose Lew(Chapter 9(commencing with Section 7000)of dI vWon 3 of the f'-v An�
Business and Professions Code)or that he is exempt therefrom silo Me bash for the alleged A PHALTrSHINGLES - � III [�Q Ut _
exemption.Any violation of Section 7031.5 by any applicant for e permit subjects the applicant to glff
le cml Ixvnalry of not more then Uve hundred ddlareW ShIMCP�S`
❑I,as owner of the property,or my employees with wages as their sob componeefion,will co F11�V,UU
the work,end the structure is not intended or offered for safe(Sec.70",Business and Proles-
cions Code: The ConhaUor's Ucenso Law does not apply to an owner of property who builds or W D SHINGLE$ ❑
Improvas Malebo,end who does such work himself or through his own employees,pro ki that
such Improvements are not Inlentletl or off area far able.Il,however,Ura bulldelg or Improvement
Ie sold within one year of completion,the owrror-ddMar will have the burden of proving that he did
hot WIM or Improve for purpose of sale.). - O
as
am
with
Me�project(Seo 7er]f Me Business and ofessions Coda:The Contractors�
nfcense I-awadoees not PROVIDE I.C.B.O.REPORT NO.
apply to an oviner of property wfw builds or Improves thereon;dral who contracts for such projects
- with a contreclorLs)licensed Pursuant to Me Contractor's license Law. PROVIDE MFGR.INSTALUATION SPECS.
I am axempt under Sac. ,B WP.C.for MIs reason
owner Date APPLICATION!DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DEC VvRATION
I hereby affirm under penalty of perjury one of the following declaration:
-11 have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Carle,for the performance of the work for which this /L�
Permit Is and �� $eISmIC
have entl will Me performance
Worker's Co a war for Insurance as required by Section or 0l l/
the Lebon Cada,for Me performance of Me work a which Mb permit Is Issued.My Worker's
Component] Insurance carrier and Polity number are: � Total
Carrier S� rull-� policy No.�yL -99G.7e4oeb87 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
'(This vection need not be completed If the permit Is for one hundred"lure($1 W)or lose.) Y �/
I certify Mat In the performance of the work for which this permit Is Issued,I shell not employ
any person In any manner so as to become suNW to Lha Worters'Compermanon Laws of call- All roofs shall be inspected prior to any roofing material being
forbid. installed. If a roof is installed without first obtaining an
Date� Applicant �bl1L� inspection,I agree to remove all new materials for Inspection.
NOTICE o A (CANT: If,after rol thismate of Exemption,you should become Applicant Understands and will cam
Subject to Me Workers'Compensation provisions of Me Labor Care,you must"Irwith comply PP ply with all non point
with such provisions or this permit shall be doemod revoked. sregulations.
I carify that I have read this application end state Met the above Information b comect.I agree //��
to comely wIM ell city and county ordinances and state laws Widt ng to building construction,and II roof Cover S IO lass U...pr better.
hereby authorize rvposechaall of Mb city to enter upon Me above-mentioned properly Mr m- Dec. !% p p
spectlon Purposes. O 23 /
(We)agree to save,IndemNiy and keep l armlaea the City of Cupertoo agdata IIebIIMes,
Judgments,costs and expanses which may In any way accrue against said City to consequence $I ATURE OF APPLICANT ATE
al Me granllrg of MIs permll.
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
O FFICE'COPY
CITY OF CUPERTINO
1 of 1 BUILDING PERMIT RECEIPT OPERATOR: nencyc
COPY q 1
Sec: Twp: Rng: Sub: Blk: Lot:32613020.00
DATE ISSUED.. . .. . .: 08/23/1999 r
RECEIPT q.. . . . . ...: 9879
REFERENCE ID q ...: 99080162
SITE ADDRESS . . . ..: 10550 N FOOTHILL BLVD
SUBDIVISION . . . . ...
CITY .... . . . . . . ... : CUPERTINO
IMPACT AREA . . . ... .
OWNER ... . . . . . .... : FONTENOT ROGER M TRUSTEE
ADDRESS . . . . . . .... :
CITY/STATE/ZIP ... : LOS ALTOS CA, CA 94022
RECEIVED FROM ... . : TIM
CONTRACTOR ...... . : WILLIAMS, THOMAS LIC 4 6341
COMPANY . ......... : WILLIAMS ROOFING
ADDRESS . ........ . : 10314 LAS ONDAS WAY
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
TELEPHONE ... . . . . . : (408)866-9442
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 11,000.00 167.00 0.00 167.00 0.00
BSMICRE VALUATION 11,000.00 1.10 0.00 1.10 0.00
PERMIT 169 10 0.00 168 10 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 168.10 5716
------------
TOTAL RECEIPT 168.10
VOICE IO DESCRIPTION VOICE ID DESCRIPTION
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 6D4 ROOF IN-PROGRESS
•