99110035 5c7 q 1 00 ,3S
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBE
INSPECTION DIVISION PERM IT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
IM DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
9,e`,9, RESIDENIl COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes–1 understand that a Class A
NAME ✓1'Yl – / roof assembly is required.
NO ❑ Initial- I.C.B.O.k
ADDRESS— EXISTING ROOF COVERING
PHONE L D S NUMBER OF EXISTING COVERINGS /
CONTRACT 'S /
TO BE REMOVED L TO BE RETAIN D
NAME
ADDRESS �y�U Z / '_ �- , \^ B 9 6UISTING PE F ROOF
COl
CITU 8 ZIP
�)M' A.i7i f��fc ,
PHONI!( J /� 7—Z7PZ /!
,CENSE ,/ p BUILT-UP ROOF 7
y
NUMBER
ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
70%))of Division 3 of Ne Business ark Professions Code,and my license Is In lull force and ,......
eftecl l� 39 6 / WOOD SHINGLES
Unease Chis Lic.Number / n
s
Date O OTHER(SPECIFY)
OWNER-BUILDER l' ❑
BUILDS NOV 1
R DECLARATION PROPOSED
.7031. ,Butffirm the, am exempt from Ne le: Any ors
License law for the follorequires
ng reason. I I
(Sec.]03 aft Buslnese and Professions re Code: Airy urs or county which r;e also
ds a a putout rn a 000
apply art,or each Permitirme,t file a signed
sed stapair ementruolum,prior licensed pumice,to
he pr Anions BUILT-UP ROOF ❑ -
eplllcen,for such Permit to flaw a signed r9(com i Na,he Is Ineasetl 7000)of
the pro of Me BY
of the
ss and taro License Law(Chapter 9(commencing with Section me b of for the 3 0l Ina
Business end viefasabnv Coda) 7that he U exempt therefrom al m the lesls for the alleged to ASPHALT SHINGLES �—
axemptlen.Ary f act on of Section]hundred
d any s(n0 ).for a pamN eu0jeds the applicant to
e civil peneiry of rw1 more than(rve huntlred tldlem(5500).):
❑I,asownerol the property.ormyompbyeaswithwegesastheirwWcompense.Ion,wil WOOD SHAKES ❑
Me work,ark the structure Is not Intended or offered for sale(Sec.7044,Business and Prolelo-
Mans Cade:The Conta lora Ucenen Law does rot apply to an owner of property who builds or WOOD SHINGLES ❑
such improves thereon,and who doessuch worked for orthrough e own WIkryaes,Improved Net
suchd within
one years not Intended or offered for seer.I(however,the en of pr or Improvement
not Wild
or one yearof
purpose of ,the owner-builder will havethe burden of proving,hathadid OTHER(SPECIFY)
not buffo or Improve for purpose of sale.). 10
�/^
❑1,as owner of the property,am exceusiveay conlrecgng with licensed contractors to can itruct 20 93
Ne project(Sec.7054,Business and Professions Code:The Contractors License Law dare but PROVIDE I.C.B.O. REPORT NO. EA
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractor(s)Iceland pursuant to the Contractors Ulcers Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt esker Sec. ,B 8 P.C.k r this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the fallowing declaration;
❑1 leve and will maintain a Cemlticit a of Consent to aelf Insure for Workers Compensatlon, 0� Building
as provided for by Section 3]00 of the Labor Code,for the performance of Ise work for which this
oe '"�60Btl' �� 5 Q9 /1, 760 Seismic
�J^y�I have and will maintain Workers Compensation Insurance,as required by Section 3700 of
In Lt
Code,for the perlamance of Ne vital for which this permit is Issued.My Workers
Camperuatbn Jnsyr9gq ca Icym/mber are:�i - �D����� Total
69, Yo
Carrier, /�L// //L'lL cyNry, jm PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not bu completed it Ne permit Is for one hundred dollars($100)or less.)
I termly that in the performance of Ne work for which Nls permit Is Issued, shell not employ
any person In manner loo as to baccxTe suljec,to Ise w erre'compeoe an Lawn m Ca11- All roofs shall be inspected prior to any roofing material being
fprns installed. It a roof is installed without first obtaining an
Dao Appliesat inspection,I agree to remove all new materials for inspection.
NOTICE TO APPL ANT: 11,after making Nie Cemifical of Exempibo,you should become Applicant understands and will comply with all non int
subject to the Worlerlo'Comeentatlon prm sions of the Labor Code.you must forthwlN comply PP P Y PO
with such provisions or this permit shall be basal revoked. source regulations.
I certify that I have read this application and state that the above Information Is correct I agree
to comply with all city and county ordinances and state laws relating to Wilding mnsiruclfon,and All roof coverings a CIaSS or better.
hereby purposes.r representatives of thus city to enter upon the abare-mentioned property for in- �
spectrin purposes.
(We)agree to save,Indemnify and keep harmless Ne City of Cupertino against IlabllXles,
judgments,costs and expervses which may In any way accrue against load City an Consequence SIGNATURE OF APPLICANT DATE
of the granting of this permit.
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: christYa
Sec: Twp: Rng: Sub: Elk: Lot:32613105.00
INVOICE DATE...... : 11/05/1999
REFERENCE ID N ... : 99110035
SITE ADDRESS . . . . . : 22271 KENDLE ST
SUBDIVISION . . . ....
CITY .... . . . . .....: CUPERTINO
IMPACT AREA .......
OWNER . . . ......... : WERNER WILLIAM L AND ANN K TRU
ADDRESS .......... :
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-1024
CONTRACTOR ....... : PETERSEN, JAMES LIC H 14030
�■ COMPANY ...... . . . . : PETERSEN-DEAN INC
ADDRESS ..... . . . . . : 7980 ENTERPRISE DR
CITY/STATE/ZIP ...: NEWARK, CA 94560
TELEPHONE . . . .....: (510)494-9982
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
--------- ------------ -----------
19-.40 0.00 198.40
ID DESCRIPTION
�.....DESCRIPTION VOICE ID, ......
305 FRAME 307 INSULATION
601 ROOF YEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS