99110024 35° Z acyRI 00�
PERAMM
APPLICATION FOR CITY OF CUPERTINO NUMBE
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WRHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL/
COMMERCIAL OTHER
OWNER'S 1 l HAZARDOUS FIRE AREA
VES ❑ 11yes—Iuntlersandthat
NAME [ 1 V///VVVVv roof assemdy is required.. ClassA
NO ❑ [rawLC.B.O.p
ADDRESS 10ZC1 `��` `�` �L COVERING
PHONE 2 -5� I NUMBER OF EXISTING COVERINGS
C 5
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS E OF ROOF COVERT
Cln a ` EXISTING
/
• RHO BUILT-UP.ROOF ❑LICENSE
NUMBER I ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION v
I hereby alllrm that I am learnsed under pro islore of Chapter 9(commenxdrg with Sectlon WOOD SHAKES
7000)of DMsim 3 QI me Qysiness end Profeaslons Code,enc m license Is In lull force and -
effect. - r_//',11 WOOD SHINGLES ❑
ucense lo Llo.Number
OTHER(SPECIFY) ❑
Dale Contract
OWNER-BUILDERDE TION VV
PROPOSED
I hereby affirm that I em exempt from the Contro lale License Law for the following reason. PT
(Sec.7031.5,Business and Professions Code: Any city on county which requires a permit to rL{I,I-II
construct,after,Improve,demallsh,or repair any,structure,prior to Its Lveuance,also requires the BUILT-UP ROO D '
applicant for such pore t to file a signed statement that he is Ilcersm pursuant to the provisions
of the Contractors Ucenae Law(Chapter 9(co mienxd with Section 7000)of DMsim 3 of the
Business and Professions Code)or met he Is exempt Merefrom and the beets for the alleged ASPHALT SHI ENOV _ 4.9Qgg
exemption.Amy violation of Section 7031.5 by any applicant for a permit subjects me applicant to �o
a evil penally of rut more than five hundred dollars
C]1,as owner of the property,or my employees wllh wages as melr sole compensation,will do WOOD SHAKE ❑
the work,sod the structure Is ml Intended or offered for gals(Sec.7044,Business and Pratte. - ,p
eons Code:The Conthxfors License Law does not apply to an ownrer of property who bulMs or WOOD SHING &
Improves thereon,and who does such work hlmaeff or through his own employees,provided that
such IrtprovamenLs are not Intended a offered for sale.If,however,the bulldhg or Improvemem
Is sold within one year of completion,the owner-bulkier will have the burden of proving mat he old OTHER(SPECIFY)
not build or Mprove for purpose of sake.).
E]1,as amen of me properly,am exckusivaty contraclln with licensed contractors to construct
4 Bmle
me project(Sec.704usiness entl Psak ns Code:Tire Contractors Uceisse Law does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who Wilds or improves thereon,and who contracts for such projects
wish a contractors)licensed pursuant to the Contractor's kxenaa Law. PROVIDE I INSTALLATION SPECS.
❑1 am exempt under Sec. ,B 8 P.C.for this reason
owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under Penalty of perjury one of the IollvM g declaration: { /1
❑Ihave
or byS ctim 3700 of filicate bor Consent theeerformefor Workers Compensator, O� Building
es provided ford !main ain aC the Labor Code for the performance of the work for which INa I l.J(Il/'
AIUs Issued. SBISmIC
have end w111 maintain Waken s Compeneabon Insurance,es requlred by Section 3700 of
e bon Code,for the performance of th work for whits this permit b shouse.My Workers No �7Q
Corryreneeoon Insaianca and PoI' mbar ere: n Total O
IIS- oZ
tamer r Policy PERMIT AUTHORIZATION DATE
CERTIRCATE OF EXEMPTION FROM YORKERS'
COMPENSATION INSURANCE N.C.0
mus section read rot be completed if the Permit Is for one hundred dollars($100)or lass.)
I cerdly that In the performance of me work far which this permit Is Issued,I shall rut employ
any parson In any manner so as to become subject to the Workers'Compensation Laws N Cali- All roofs shall be inspected prior to any roofing material being
fOf1lo. installed. If a root is installed without first obtaining an
Date Applicant Inspection,I agree to remove all new
[[[777materials for inspection.
NOI TO APPLICANT:.If,after making this Cendfcate of Exemption,you sMlulo became A IlCant understands and will C I with all non int
subject to the Workers'Compensation proovudonu of the Labor Code,you must IortI campy pp c ply PO
with such provisions or this permit shell be dammed revoked. source regulations.
1 centrty that I have reed this applicable and state that the above information Is correct-I agree
to comely with 0 city ani county ordinances end stale laws relating to binding mnstrucllm,and Allr verings be class or better.
hereby authorize representallves of the city to enter upon the above-mentioned property for in-
spectibi pu�,. cu LZ -Q l t �i
(We)agree to save.Indemnify entl keep harmless 17re City of CupertNo against Iledlllles,
of 1 r�e nt nim a wbe expekpeouretns.�which my In arty way e«rue against said!City In consequence GNATURE OF APPLICANT D E
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: R g: Sub: Blk: Lot:34245006.00
INVOICE DATE......: 11/04/1999
REFERENCE ID # ...: 99110024
SITE ADDRESS .....: 10398 KRISTA CT
SUBDIVISION .......
CITY . . ........... : CUPERTINO
IMPACT AREA ...... .
OWNER ............ : GEE, DAVID
ADDRESS ........ .. :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2612
CONTRACTOR ... . . . . : KAHN, RUSSELL LIC k 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
__ _ --- --------- ------------ -----------
BPERMEEE P 207.00 0.00 207.00
BSEISMICRE P 1.50 0.00 1.50
--------- ------------ -----------
208.50 0.00 208.50
t� ID ------- DESCRIPTIONDESCRIPTION
_-------- VOICE ID ----__
-------
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS