99090092t
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11
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990 9009.& PERMIT
r APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(4W) 777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS n
/0 (9� � ""''
RESIDENTIAL COMMERCIAL OTHER
- -
owNER's/l"�f
RD FIRE AREA
C]YES ff yeaunderstand thatClass A
NAME t -_•GCS
roof ass sembly is required.
NO ❑ _ InitlN LC.B.O. N
'ADDRESS—
EXISTING ROOF COVERING
/
T - -
PHONE 9 —1-57-33
NUMBER OF EXISTING COVERINGS
/
TO BE REMOVED _ T.O E RETAINED
CONTRO�
AC n
NAME
ADDRESS ��/O ii „_n_YFG _ ._� 1
CITV&ZIP TD pL�/ VT GfpN�
�ji� TYPE OF BdW__QQVFE1ING
Y -i
ExIsnNG
L!
A 6 7/ V
—
?HONE -� �/ 7
BUILT-UP ROOF
LICENSE / po /, /
NUMBER' (p0 ,7'Y
ASPHALT SHINGLES ❑ °I!7
UCENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 0 (commencing with Section
WOOD SHAKES
7000) of DMslon 3 of the Business entl Professions Code, and my license in In lull orm and
effect.
WOOD SHINGLES ❑
Ucense ClUc. Number ,0
Date Cant rddor
OTHER (SPECIFY) Q
Lrz�
OWNER.BUM'ER DECLARATIO
I hereby affirm that I em exempt from the Contmctars License Lew for the blowing reason.
PROPOSED In
i
D
(Sec. 7031.5, Business arid Protestations Code: Any city or county which requires a permit to
construct, after, Improve, tlemoiah, or repair any structure, Odor to Its Issuance, also requires Me
for to his he Is licensed
BUILT-UP ROOF SEP 1 S❑1999
applicant such permit a signed statement that pursuant to the onwIslons
of the Contractor's License Law (Chapter a (commencing with Seaton 7000) of DMson 3 of the
f
i
Business arm Professions' Code) or that he is exempt therefrom and the bass far fire alleged
ASPHALT SHINGLES ❑
exemption. Any Nolatlon of section 7031.5 by any apdicent for a permit subjects the applicant to
-
e dull penalty of not more then five hundred dollars (f500).):
LPy—
iV_❑I,ds
WOOD SHAKES
[] 1, asnner of I tmy ended7yeffered wages as, theirsale compensation,ssand Prof do
Oe work, erM the ekuaura le not Intended ores for sale 044, Business end or
Li
-
n(Sm.
Lew damenot
not roto c,om of property who wildsor
rope ulMs
- WOOD SHINGLES ❑
'Imp'Code:The,aniraaod such orhis
uch Imp thereon, entl who tlaen each work himself or through hie own em ilding or morcie Met
such Improve me ms are not Intended offered for idle. If, however, the or
IaWd oneyear the
the ownerbuloer wW have Me burden of pravMpthat he did
en of g mat he did
OTHER SPECIFY L.F+
(
or purpplatlon,
not build or Mpove lion purpose of Belo.).
tbuldor
�
❑ I, as Owner of the property, am exclusKily conbeaing with licensed contractors to construe
Me project (Sec. 7014, Business and Professlons Code: The Contractor's License Lew, does not
PROVIDE I.C.B.O. REPORT NO. S ZI
apply to an owner of property who bul Ids or Improves Oereon,"who contracts for such protects
with a contractors) llmnned pursuant to the Contractor's License Lew.
PROVIDE MFGR. INSTALLATION SPECS.
E]I am exempt under Sec. ,B 6 P. C. for this reason
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATCN
I hereby affirm under penalty of penury one of the fotlO ing declaration:
I neve and will maintain a Certnkate of Consent to self -Insure for Workers Compemoton,
as provided for by Section 3700 of the Labor Cade, for the performance of the work for which this -
oe�r tl`e_le_suetl.�9_0
Building (ysL
8b
on as ramris Section 3]OO
entl will maintainpert Worker's Cope
Seismic
whichnce, of
Labor Coda, br the performance of Me work for which this permft b leeuetl. My Workers
7 work i su
Total
C
Cornpensatlon Ins nm er d Polley number are: I- y
�4GG 1103-90
PERMIT. AUTHORIZATION
DATE
Carrier PdicyNo.
• CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(Tits eecibn need not be compbted I Oe permit is for one hundred ddlars ($100) or lees.)
I cantly Met In Oa performance of the work for which Ole permit Is Issued, I shall not employ
any person In any manner so as to become subject to the odcers' Compenaauon Laws of Call-
All roofs shall be inspected prior to any roofing material being
1°`ma. /�
9 /•1 /..7- -
installed. If a roof is installed without first obtaining an
Date ,palest
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, she, making OIs Cortficiffe of Exemption, you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
with such provisions or tine permit shall be deemed revoked.
source regulations.
I cortlty that I have read thio eppumtlon and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to bulltling construction, and
All roof coverings to be Class Of better.
hereby authorize representeevee at Ole city to enter upon the above-mentioned property or In-
henrys
- /
purposes,
purposes.
/y�
��
(We) agree to save, Indamnity and keep henmfaas the City of Cuperew so= Ilebt lies,
l//'�) `'
All, �Z7
tudamenta, ween and expenses which may In any way accrue age]= said City In consequence
of the granting of lits permit.
SIGNATURE OF APPLICANT 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: nancyc
Sec: Twp: Rng: Sub: Blk: Loc:35618003.00
INVOICE DATE......: 09/14/1999
REFERENCE ID # ...: 99090092
SITE ADDRESS .....: 10990 MARIA ROSA WY
SUBDIVISION .......
CITY .............: CN?ERTINO
IMPACT AREA .......
OWNER ............: REED ARTHUR M AND JEANNE K TRU
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4]20
CONTRACTOR .......:
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP .... ,
TELEPHONE ..... ...:
FEE DESCRIPTION CHK TOTAL FEE
BPERMFEE P 137.00
BSEISMICRE P 0.80
13] BO
VOICE ID DESCRIPTION
• FRAME
-------------------
601 ROOF TEAR OFF
603 ROOF BATTENS
0
LIC 4
PAID -TO -DATE
BALANCE DUE
--------a---
.00
-----13] 00
0.00
0.80
----------oo
0.
-----13] BO
VOICE ID DESCRIPTION
30] INSULATION
602 ROOF PLYWOOD NAIL
604 ROOF IN -PROGRESS
I• 1 of 1
CITY OF CUPERTINO
BUILDING PERMIT RECEIPT
Sec: Tp: Rng: Sub: Blk: LOc:35618003.00
DATE ISSUED.......: 09/14/1999
RECEIPT N.........: 10072
REFERENCE ID N ...: 99090092
SITE ADDRESS .....: 10990 MARIA ROSA WY
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: nancyc
COPY ff : 1
OWNER ............: REED ARTHUR M AND JEANNE K TRU
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4720
RECEIVED FROM ....: TIM
CONTRACTOR .......: LIC N
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP ....
TELEPHONE ........:
FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS RED
__________ _________________________________ __________ __________
BPERMFEE, VALUATION 8,000.00 137.00 0.00 137.00
BSEISMICRE VALUATION 8,000.00 0.80 0.00 0.80
I• PERMIT : 137.80 0 00 137.80
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ____________ ------- ___________
CHECK 137.80 10256
TOTAL RECEIPT 137.80
VOICE ID DESCRIPTION
........ ...................
305 FRAME
601 ROOF YEAR OFF
603 ROOF BATTENS
0
VOICE ID DESCRIPTION
........ ...................
307 INSULATION
602 ROOF PLYWOOD NAIL
604 ROOF IN -PROGRESS
NEW BAL
0.00
0.00
0.00