99110026i
APPLICATION FOR CITY OF CUPERTINO
REROOF PERMIT INSPECTION DIVISION dPW
(408)777-38
Wml 180 DAYS OF PEF M ISSUANCE OR
180 DAYS FROM LASTCALLED INSPECTION,
BUILDING ADDRESS
/�I_
/ / / RESIDENTIAL COMMERCIAL OTHER
OWNER'S I AZ
HARDOUS FIRE AREA b
YES ❑ N yes-I understand that a Class A
NAME �Cy o, /YUYU roof is required. '
NO assembly
I.C.B.O.R
ADDREss�, , ,C',.L��rJ EXISTING ROOF COVERING
PHON 4, NUMBER OF EXISTING COVERINGS
CO
NAM / Y250 1101" R
L9i TO BE REMOVED TO BE RETAINED
ADDRESS ^ ,, �SS TYPE OF ROOF COVERING
CIN a ZIP h _ EXISTING
PHONEIJfM/ y�k'45;169Y BUILT-UP ROOF ❑
LICENSE SS9 �3
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECI-ARATION
I hereby affirm that I em licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Dfvlaion 3 of the Business and Professions Code,and my license is in full force and
effect.
� � WOOD SHINGLES E]Dax Dae C-
ena3� Lia.Number ySs9,7 3 6
/Q
Date contractor AWIS5�yxo {�� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
a
I hereby affirm that I am exempt from the Contraclers License Law for the lollowing reason. E
(Sec.7031.5,Business and Professions Cada: Any city or county which requires a permit toconstruct,alley,Improve,demolish,Or repair any structure,prior to ria Issuance,also requires Ne BUILT-UP ROOF
applicant for such permit to We a signed statement that he Is licensed pursuant to the provisionsof the Conlrectors LIcense Law(Chapter 9(commanding with Section 7000)of Division 3 of the Business antl Protest Code)or.that he Is exempt therefrom snot the basis for the alleged ASPHALT SHINGLES1999
exemption.Any violation of Section 7031.5 by any oWlkani for a permit subjects the applicant to
a civil penalty of rot more than We hundred dollars(SSW).):❑1,es owner of the property,or my employees with wages es their sole cumpensatlon,win do WOOD SHAKESthe work,and the slmcture is not intended or offered for sale(Sec.7044,Business ami Proles.
sldnecode:The contractors LIoerse Law does not apply to an owner of property who halms orWOOD SHINGLES Improers thereon,end who does such work himself or through his own employees,Ixovldeel Cre1
By—
such Improvements are rot Intended or offered for sale.It,however,the building or improvement
b told wlWn me year of completion,the owner-Wilder will have the burden of proving that he did OTHER (SPECIFY) C-1
not build or Improve for purpose of sale.). I
❑I,as owner of the property,am exclusively contreci ng with licensed contractors to constrict 7-1 If 4L
the project Sm.7044,Business and Prefixal Cade:The Contractors License law does not PROVIDE I.C.B.O.REPORT NO. 2A 1
apply to an owner of property who builds or knproves thereon,end who contracts for such projects
writ a contractors)licensed pursuant to the Convectors LIcense law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B d P.C.for Ids reason
Owner Date APPLICATION DATE VALUATION PERMff FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of consent to"if-Insure for Workers Compensation, Building
as provided for by Section 37W of the Labor Coda,for the performance of the work for which this
m
permit Is issued. Seismic
and will maintain Workers Compensation Insurance,as required by Section 37W of
the or Coda,for the performance of the work for which this permit b Issued.My Worker's Total
Compo^�etio,n--Inturence carrier e� icy`umber ere: vJ Total
Carrier Q✓1 Curl IYri 1 'Ln?_ PolkyNo. 5�R�23 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.0[� I '�
(Thio section need not be cartlpleted if Ito permit b for one huMred dollars(St W)Or less.) /l
I certify drat In the performance of Me work for which this permit Is Issued.I shell rot employ
aay parson In am manner w as to become eubjrct m the Work Compensation laws Of call- All roofs shall be inspected prior to any roofing material being
forms. installed. If a roof is installed without first obtaining an
Dale //- Y'9`f Applicant / inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: If,after maWng this Codilicate -empilon,yd17 should beacma Applicant understands and will coon
subject to the Workers'Compensation provisions of the Labor Code•you must forthwith comply pP ply with all non point
with such provisions or this permit shell be damned!revoked. Source regulations.
I teddy that I he"reed this application and state that the above Information is correct.I agree
to comply wlth all dty and county ordinances and state am rotating to bulming construction,and All roof covering7a.aClass better.
hereby authorize representatives of this city to enter upon the above-mentioned property for in-
spection purposes. �/
(We)agree to rave,Indemnify and keap harmless fire Cry of Cupertino against Iladlities, a✓'}i l/- 7 9�
Judgments,costs and expenses which may in any way accrue against saki Dry In consequerore
of the greodng of this permit. SIG TUR PPLIC T DATE
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: Blk: LOC:36206037.00
INVOICE DATE......: 11/04/1999
REFERENCE ID # ...: 99110026
SITE ADDRESS .....: 21448 KRZICH PL
SUBDIVISION .......
CITY . . . . .........: CUPERTINO
IMPACT AREA ...... .
OWNER . . . . . .......: TRURO LEE F AND ELIZABETH J
ADDRESS . . . .......:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4943
CONTRACTOR ....... : DADDARIO, STEVE LIC 4 20739
COMPANY .......... : RENAISSANCE ROOFING CO INC
ADDRESS .......... : 2292 LINCOLN AVE
CITY/STATE/ZIP ... : SAN JOSE, CA 95125
TELEPHONE ........: (408)448-0697
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
_______________ ___ ______--- ------------ __-__-_____
BPERMFEE P 267.00 0.00 267.00
BSEISMICRE P 2.10 0.00 2.10
_________ ____________ ___________
269.10 0.00 269.10
l ID ------- DESCRI PTID= VOICE ID - DESCRIPTION
-- -------- ------ ..-...........
FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
i