99110114 3 ` 2 94> >oaaL1
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBE4MNAW]
INSPECTION DIVISION PERMIT E%PIRATION
REROOF PERMIT (aos)777-3M PERMIT EXPIRES IF WORK IS NOT STAR ED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
I�(/ ///
•� � • fill "' I15o `' RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a ClassA
''//
NAME k_ roof assembly is required.
I C � V�'�\ (J\(,/� NO ❑ IRO Ll
ADDRESS
y EXISTING ROOF COVERING
PHONE
: NUMBER OF EXISTI G COVERINGS
CONTRACTOR'S �— I I
UkATO10 BE REMOVED TO BE RETAINED
NAME ' I
ADDRESSL�A TYPE OVERIN
CITY 8,ZIP
EXISTING /
PHONE � BUILT-UP ROOF
LICENSE - /�
NUMBER � ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION 17
Hereby Daffirmivision
that em licensed under provisions of Chapter 9(coma eis in with f rce and WOOD SHAKES
]000)of DlNsbn 3 0l the Bu oes and Profesebns Code,and my license is in full force entl '
effect. / ,,tq LO
,,/L WOOD SHINGLES El
License Class Lk.Number b 4 LO
Date Contractor OTHER(SPECI --� ❑
OWNER BUILDER DECLARATION ROP ED I
I hereby affirm that I am exempt from the Commdore License Law for theQowrg reason.
(Set.7031.5,Bushness and!Professions Code: Any chy or county which raqures a parout 11 QQ
consimd,eller,improve,demolish,or repair any structure,Prior to Its Issuance,also requires the BUILT-UP ROO NpV 1 �9 V"
appiaanl for such permit to file a signed statement hat he is licensed pur u rd to the prwlslonv
of the ConVactor's License Lew(Chapter B(oortmerwing with Secllon]000)of DMsion 3 of the
• Business and Professions Code)or mel he le exempt therefrom and the basis for the alleged ASPHALT SHIN ES ❑
exemption.Arty vblstlon of Section 7031.5 by any applicant for a permit su facts the applicant to
a civil penalty of rnet more than live hundred sonars(M).): WOOD SHAKES B
I,as owner of the property,or my employees with wages as(heir sale compensatlan,will do Y
the work,and the elructure Is not Intended or offered for Shia(Sec.]OCs,Business am Prdae-
sions Code:The Cuntredors Ucanse Law tlaes Trot apply to an owner of property who Wide or WOOD SHINGLES
Improves thereon,and wine does such wom himsell or through his own employees,provided that ❑
such Improvements are rnet Intended or offered ar sale.If,however,me Gilding or Improvement
Is said within one year of completion,the owner-builder will have the burden of proving final he did OTHER SPECIFY
rnet bola or Improve for purpose of
saill
I,as owner of the propertyexclusively am ezdusivaty cu Cade:
with licenceds Licadoma to constroct r'�
theipplyto norwrourofprperty h Wildsolessons gerovCade:Theand hoc cinLicenseLewdoesnot PROVIDE LC.B.O.REPORT NO.
apply to contractor(s)
property who Wilds or Ie Contr8thereon,era whotonimca for such pmjeds
with e c m exempt
un e r eadSer°urea°ni to the Contractor's license Law. PROVIDE MFGR.INSTALLATION SPECS.
1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Date
WORKER'S COMPENSATION DECLARATIONAPPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of p nhury one of the Idlowlng declaration:
' ❑I have and will maintain a Certlflcae of Consent to sen-Insure for Workers Compensation, �'1�'-��\ Building
IS provided for by Section 3700 of the Labor Code,for ma perbrmence of the work for which this I //(/(// I'1 ! 1 11 1 g
par a issued. ,r/ ` / ✓ CDC) Seismic
X
end willfor the peln Workers f the w lk for Ire Ich ce,INS as required!Is I su Sedan 3]00 of
he or Codo,for the pedormarce of the wo for which INS permit Is Issued.My Workers �//� .�
Comperwaion nsura carrlergay Pdlcy nu r ere: TOtal�r
Cedar \r�;Vrtl wllgNo9t5 PERMIT AUTHORIZATION DATE
-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CC
(This section hood not be completed It the permll Is for one hundred dollars($100)or less.)
I certify that In the performance of the work for which cols permit Is issued.I shall aht employ
any person In any mannar so as to become subject to the Workers'Con-Wnaeuon haws of Can- All roofs shall be inspected prior to any roofing material-being
k ia. installed. If a root is installed without first obtaining an
Dais Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT:ompe alta making this Certificate Lab of ode,your mus rfo�wtlhmply Applicant understands and will comply 'th all non.point
me
subject tome Workers'Compensation aster rMg this of me Leber Code,
with such provisions or this permil shall be deemed mocked. Sourcere Ons.
I certify that I hese read this application ar<1slate that the above information Is correct I agree
to comply with all city and county ordinances and state awe relating to bulltling construction,and All rODf Ove gS to be $S Ci`of tte .
heretry authorize repreaenlelWae of this city to enter upon the above-memiored property for In-
specition
(We)
purposes. J
(we)agree to save,e pensesIndemnlw and keep harmless ffilSochi
City tai Cupertino Ci ygelnst liabilities,
Judgments,
ffdthhe granting of enld tau. which may m any way accrue egeaat Sam city m toreequeue SIGNATURE OF APPLICANT DATE
• PRE-INSPECTION: PLYWOOD: `3 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
OFFICE COPY
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: chrlstya
Sec: Tp: Rng: Sub: Blk: Lot:34245005.00
INVOICE DATE. . ....: 11/19/1999
REFERENCE ID # ...: 99110114
SITE ADDRESS .....: 10388 KRISTA CT
SUBDIVISION ...... .
CITY . . . .......... : CUPERTINO
IMPACT AREA ...... .
OWNER ............ : TAYLOR PATRICIA B AND JOHN P
ADDRESS ........ . . :
1 CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2612
CONTRACTOR .. . . .. . : KAHN, RUSSELL LIC # 17999
COMPANY ..... . ....: CROWN ROOFING INC
ADDRESS .. .. . .. ...: 214 CRISTICH LN
CITY/STATE/ZIP ...: CAMPBELL, CA 95008
TELEPHONE . . ......: (408)369-7444
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
ID ............................DESCRIPTIONVOICE ID ---- DESCRIPTION
........ ... ...............
5 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•