99120146 -2- I Z'O ► 4
PERMIT
APPLICATION FOR CITY of CUPERTwo NUMBER
INSPECTION DIVISION PERMIT EXPIPAI N
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR'
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
Z0�53 coree�nler�� ��� �Sv�4
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ N yes—I understand f1Nf a Class A
NAME roof assembly is required.
❑ I.ce.o.r
ROOF
ADDREss W \ 2 �^ EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING RINGS I
CONTRACTOR'S -
TO BE RETAINED
TO BE REMOVED
NAME
ADDRESS I RIN
CITY 8 ZIP EXISTING
PHONE 1 BUILT-UP ROOF//
NUMBER ASPHALT SHINGLES
UCEN9ED CONTRACTORStomsof Captor 9
")retry effinn Ilial 1 am Ilcaneatl under Professions
lone of Chapter a(cams eis In with Section WOOD SHAKES Ci 2 9 1999 .
]000)01 ONWon 3 of Ne Byelrbaa eM Proleaelona Code,eM my license le In lull force aM
effect. �i/7/Ll WOOD SHINGLES
LiceDam sa Uc.Number
OTHER(SPECIFY) � —
Deb Confrector
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contramor'e License Lew for the fol nA g res
(Sec.7031.5,Sualnesa and Professions Code: Any dry or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a signed statement that he Is Ilcenaed pursuant to the provWons
of the Contractors Ucense Law(Chapter a(commencing with Search 7000)of Division 3 of the
Business and Profmal Code)or Chet he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any vloletbn of Section 7031.5 by arty applicant for a permit subjects the applicant to
e civil penalty of rot more than Ove hundred dollar,(5500).):
C]1,as owner of Me property,ar my empbyeee with wages as Cher ode compensation,Wil do WOOD SHAKES ❑
Me work,al Me structure Is not Intended or offered for sale(Sec.7044,B&nk)sa and Proles-
alone Code: The Contractors Ucerroe Law does not appy to an owner of property who builds or -WOOD SHINGLES
Improves thereon,and who does such work himsell or through his own employees,provided Met El I
such Improvements are her Intended or allered ler sale.If,however,the WIMlrg oc Improvement
is sold within one year of completion,the ovmerbulider will have the burden of pneumo Mat he tllo OTHER(SPECIFY)
not build or Improve ler purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to canetruct
Me
Project(Sec.7044,Bualnesa and Professions Code:The Canirectore Ucenee Law dose trot PROVIDE I.C.B.O.REPORT NO. t O
appy to an owner of Property who W Ilds or Improves thereon,and who contracts ler such projects
with a contractor(s)lice
ctor(s) nsed pursuant to the Contractors Ucernee Law.
of
em exempt ureter Sec. ,B a P.C.for the reason PROVIDE MFGR.INSTALLATION SPECS.
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under peraly of perjury one of"follc ing deciereton:
❑1 have and will maintain a Certificate of Corte l to sell-Insure for Waders Compensation, �1. Building
sa prcvmcl ler by Section 3700 of Me Labor Code,for Me Performance of the work ler which this I.,, I^�I�C g
salt le Issued. /_�Il KJ f{ 'YL�CED Seismic
ave end will maintain Workers Compensation Insurance,as required by Secton 370004 /� � �
e Labor Code,ler the pertaenence of work ler wNch Ws persalt Is I ad My Workers `9�r"f �J
Comperusul Insurance saMer erxl l mbar ere: ,S Tota ,
Cerner PdlcyNo.�!//. PERMIT AUTHORIZATION DATE
CEOMFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This settlor need not be completed If We permit Is for one hundred dollars($100)or less.) —� P
I cenlfy,that In the performance of the work for which this permit Is Issued,I shall rot employ Z—1-P
—
any peraor In any manner so as to become aub*t to Me Workers'Comp,neaticn Lawn of Call- All roofs shall be inspected prior to any roofing material tieing
fornix. installed. If a roof Is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this CertlHcete of Exemption,you should become comply subject to the workers'Compensation provisions of the Labor Code,you must lorthwhh conipiy Applicant understands and will Wlth all non point
win such provislons or this permit sholObe deemed revoked, source regulations.
I tartly Net l have reed this application and state Met Me above Information le cameat lagree .
to comply with all city and county ordinances and state laws relaunif to Willing crostrocllon,end Allr c eringst eclass"C" er.
hereby outhodze representatives of MIS dry re
to enter upon the abo -mantlon ad property for In.
(We)spree to,eve,Indemnity ep end kehermbsa Ne City of Cupertinoab0ltiee,lno against II
Judgments,costa al expenses which may In any way accrue salGry In against e consequence �{
of the granting of No permit. SIGNATURE OF APPLICANT DAT
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
J'.�
OFFICE COPY
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
. BUILDING PERMIT INVOICE OPERATOR: chriatya
Sec: Twp: Rng: Sub: Elk: Lot:32656003.00
INVOICE DATE. . ....: 12/29/1999
REFERENCE ID # ...: 99120146
SITE ADDRESS .....: 20653 GREENLEAF DR
SUBDIVISION .......
CITY ... . . ........ : CUPERTINO
IMPACT AREA ...... .
OWNER .. . . ........ : WANG PHILIP C AND KATY H
ADDRESS .......... :
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-1907
CONTRACTOR .... . . . : KAHN, RUSSELL LIC # 17999
COMPANY ....... . ..: CROWN ROOFING INC
ADDRESS .... . . ....: 214 CRISTICH LN
CITY/STATE/ZIP ...: CAMPBELL, CA 95008
TELEPHONE ........ : (400)369-7444
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -_"___"----
BPERMFEE P 197.00 0.00 - 197.00
BSEISMICRE P 1.40 0.00 1.40
--------- ------------ -----------
198.40 0.00 198.40
1IO ----.. DESCRIPTION.-_------ VOICE ID ____-- DESCRIPTION
.. .......... ........ .................
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•