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991200560 8 0 I 006& P _ APPLICATION FOR CITY OF CUPERTINO N e WA ' INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT' (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 190 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS _/ I �OSa+ re• �/ /T RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA //�� f I YES ❑ ftt ClansA NAME l JGl X Y,ee o5�� rd ure. NO ❑ InMal I.C.B.O. M EXISTING ROOF COVERING ADDRESS NUMBER OF EXISTING COVERINGS _/Jk PHONE TO BE REMOVED TO BE RETAINED CONTRACTOR'S {' &aj,05 �) NAME 1 V, •f—/�I�il1 ADDRESS / /! �- n po - TYPE OF ROOF COVERING _ CITY SZIP Abs Z7AI `I 3 / EXISTING BUILT-UP ROO ❑� /Y,', �jL / �f(f,LS(711d03 PHONEAT7 R'_C d / v� 3— _ NUMBER II� ASPHALT SHINaLEsOEC 8[09 D ' u LICENSED CONTRACTORS DECLARATION 1 hereby affirm Met I am Iicenseci under provisions of Chapter a (commencing with Section WOOD SHAKES ❑ 7000) of DMilm 3 of Me Bustriees and Professions Cade, and my Ncenas Is In full force end nhe" Ucense Claes 5_4� Uc. Number W 5 3 .WOODSHINGLESY ---,z_, OTHER (SPECIFY) Date contractor OWNER -BUILDER DECLARATION hereby ng , Bu Mei am exempt hon the cry Uranus Lew for the fioNcrrequires PROPOSED treason, e: Any to , Cade: Arty city or county which requires a permit cons. 7ct, Burmese and Profedish, aft uir s construct, alter, Improve, or re or repeat airy structure, prior fo 8e Issuance, no also repress Ms ofile BUILT-UP ROOF �� t flaw aChnod statement9(comm the he Is applicant for ouch perms a s p t fo the prpvof with 000) of B the ss a d or& License Law (Chapter a (commencing g weh Section 7000) of to( Me 3 0l Me a Sectio Me ern Protese Codi) or that Is exempt M and the beets for tine alleged ASPHALT SHINGLES examines on d Section b tfor a exemption. Anyf n N by any epplkent for a permit subjects the applicant to e dyll penalty al not more than five huMred dollars not hundred WOOD SHAKES ❑1, as owner of the property, or my employees with wages as their we compmeetkn, will do ❑ the work, and the structure Is not Intended or offered for sale (Sec. 7044, Business and Protea - dons Cade: The Contractors Lkense Law does not apply to an owner of property who builds or WOOD SHINGLES - ❑ Improves thereon, and who does such work himself or through his own employs", proNded the; such Improvements are not Intended or offered for sale. ll, however. Mw building or Improvement is sdd within me year of completion, the owner -bulkier will have the burden of proving Met he did OTHER (SPECIFY) E)not brad or Improve for purppse of sale.). ❑ I, all owner o1 the property, em wxcluslvMy, comracdng with licensed cor hectors to construct the project (Sec.7044, Business ern Professions Code: The Contractors Ucernse Law does not PROVIDE I.C.B.O. REPORT NO. apply to an Avner of property who bulks or Improves therem, and who centrads for such ptojecls MM a comractogs) [tensed pursuant to Me Contractors Ucense Lew. PROVIDE MFGR. INSTALLATION SPECS. E]I em exempt under Sec. ,B & P. C. for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECIARATION 1 hereby effem under penalty of penury one of the following declaration: ❑ 1 have and will maintain a CoMficate of Consent to self-Maure for Workers Compensation, Building g as provided for by Section 3700 of the Labor Code, for me perbrmence d Me work for which this permit is 1&nued. Seismic I hese end will maintain Workers Compensation Insurance, as required by Secibn 3700 of Me Labor Code, for Me performance of Me work for which this permit Is Issued. My Workers W Total Compares ir/Iwm Insurance came rJg/� Policy number are: 4OA�'Icy / y r/NoCrlW��,VaV PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE - N.C❑ Thio (&eclbn need not be completed 1 Me perms is for one hundred dollars ($100) or less.) I cerdfy Met In Me performance of the work for which Mie pemet Is leered, I shell trot employ All roofs Shall be inspected prior to any roofing material b ing any person test to the In any Mannar so as to become subworkers Compen nathm Lew& of CBIb tennis. installed. If a roof is installed without first obtaining an Date Applicant inspection, I agree to remove all new materials for inspection. - NOTICE TO APPUCANT: If, after making this CeMcete of Exemption, you should become Applicant understands and will comply with all non point subject to Me Workers' compensation provblons of Me Labor Code, you must forihwlth comply with arch provlelore or this permit Mae be deemed revoked. source regulations. I cartey that I hays read Mau application and state that the above Information i9 correct. I agree to comply MM M city end county ordinances and state laws relating to Wilding construction.and All roof cove Sto be class rbetter. hereby authorize repreeenlaLLyee of this city to enter upon Me abo mentioned property for In. spectlon purposes. %�1 (We) agree to save, Indemnity and keep harmless Me City of Cupertino egaMst Ilebili les, �� y� & I costa and expenses which Trey In any way accrue egeloat sada City In consequence SIGNATURE OF APP )CAN DATE fdemems, of t�19 granting of Mb perms. 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 INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE CITY OF CUPERTINO BUILDING PERMIT INVOICE OPERATOR: yvo"ek • Sec: Twp: Rng: Sub: SIR: Lot:35716108 INVOICE DATE......: 12/08/1999 REFERENCE ID ft ...: 99120056 SITE ADDRESS .....: 21921 HERMOSA AVENUE SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OWNER BAXTER ADDRESS ....... ...: CITY/STATE/ZIP ...: CUPERTINO, CA 95014 Ll VOICE ID DESCRIPTION 307 INSULATION 602 ROOF PLYWOOD NAIL 604 ROOF IN -PROGRESS CONTRACTOR .......: RADONICH, GARY LIC 4 17814 601 ROOF TEAR OFF COMPANY ..........: LOS GATOS ROOFING ADDRESS .......... : 1771 SMITH AVE CITY/STATE/ZIP ...: LOS GAME, CA 95030 TELEPHONE ........: (408)358-1233 NOTE: THE FEES LISTED ARE ONLY THOSE DUE BEFORE PERMIT PRINTING FEE DESCRIPTION CHK TOTAL FEE PAID -TO -DATE BALANCE DUE BPERMFEE _-_--------- P ------------ 117.00 0.00 ----------- 117.00 BSEISMICRE P 0.60 0.00 0.60 --------- ------------ 117.60 0.00 ----------- 117.60 Ll VOICE ID DESCRIPTION 307 INSULATION 602 ROOF PLYWOOD NAIL 604 ROOF IN -PROGRESS DESCRIPTION --ID 305 ------- RAME=--==a. •. F� 601 ROOF TEAR OFF 603 ROOF BATTENS Ll VOICE ID DESCRIPTION 307 INSULATION 602 ROOF PLYWOOD NAIL 604 ROOF IN -PROGRESS