99100028 33= 0 3 �
Y/-- 99/20600;—qk PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (406)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
IN DAYS FRAM LAST CALLED INSPECTION,
BUILDING ADDRESS
f�
/fit n) v I RESIDENTIAL COMMERCIAL OTHER
OWNER'S . HAZARDOUS FIRE AREA
Q kJ D MA4 f f IJ Wl �T YES ❑ If yes—I understand that a Class A
NAME - roof assembly Is required.
NO ❑ Initial I.C.B.O.O
ADDRESS C� ' y EXISTING ROOF COVERING
PHONE �Sa L� �. NUMBER OF EXISTING COVERINGS
CONTRACTOR'S rC��c�
NAME— e—
TOk./� �Lp��Q AG, yJs� TO BE REMOVED TO BE RETAINED
ADDRESS /J/ C �,rfA M,a I `/ TYPE OF ROOF COVERING
CITY B ZIP 7 (D�J I
`2BUIL— �� O 7 EX
PHONE 72 Il /1 - BUILT-UP ROOF ❑ '
LICENSE
jl�NUMBER 3G 1 '� 'Z ASPHALT SHINGLES ❑
/ /
LICENN SED CONTRACTORS DECLARATION
I hereby affirm met I em licensed under provisions of Chapter 9(commencing wlth Seedbed WOOD SHAKES
7000)of Dmsion 3 of the Business end Professions Code,and my license is in lull force and ,
effect. // // � I V
Dcanee Cleae Lic.Number
&3(x'-1 7 L WOOD SHINGLES ❑
Date 1 — V — -20 onlractor -OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATICN PROPOSED
I hereby affirm that 1 am exempt from ths Contractors 1-ceruse Lew for me following reason.
(Sec.7031.5,Buslness and Professions Code: Any city or county which requires a permit to
mralrucl,after,Improve, u h I BUILT-UP ROOF ❑
eI the C t for such permit i
I the C t lcrr sore Licerns ar 1
Bualrsss and Pmlaesbn ASPHALT SHINGLES �]/'
exemption.Any violetlon a 1" a t re nn Is pll o
a civil perslry of rat more meUn Ch
❑t as ow`aroliheprope a WOOD SHAKES ❑the work,and the structure Is iCoolTheContrsctors sorWOOD SHINGLES ❑improves tre ecn,antl who dow met
such Improvements are nd red le ho t ng
Ie seewlMlnone yearof he r t OTHER (SPECIFY) ❑
net bulld or Improve for 1
the project($eea 7gaa Ina e: an a I PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who,builds ot Improves Noreen,end who contracts lar such projects
with a contractor(s)licensed pursuant to the Contractors License Lew.
❑I am exempt under Sec. ,B It P.C.for mils reason PROVIDE MFGR.INSTALLATION SPECS.
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following deciarstlor, '
1 have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, //'' Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this
permit a issued. x/m
F]I have acct will mermaid Worker's Compensation Insurance,as required by Section 3700 01 Seismic
me Labor Cade,for the performance of he work for which this permit is lesuad.My Workers
Compensation Insurance carder and Policy number are: Total
Carrier Policy No. - PERMIT AUTHORIZATION DATE
CERTIRCATE C EXEMPRON FROM RKERS'
COMPENSATION INSU N.Co(This section need not be completed If y e permit ie for hu rs I of less.)
I certify,that in the performance of Iha work for which a permit s Issued I sh not employ
any person In any manner so ea to became subject to Workers' pen Lawn o1 Cell- All roofs shall be inspected prior to any roofing material being
forme. installed. If a roof is installed without first obtaining an
Data /0 " y 9 Appilaaninspection, I agr to remove all new materials for Inspection.
NOTICE TO APPLICANT: IL after making Nis endkate of t ptlon,yo should become A IlCant un r will Com with all non point
subject to the Workers'Compensation provsion of the Lobar a,you must rlhwlth comply PP P y P
with BUCK provisions or This permit shall be dee ed revoketl. SOU rCe reg tl DS.
corllty that have reed this appldation a tate that the ab a Informellonn}} correct agree '
to comply wimall citye�counryoNlnancasand state to"reletln �cocsiructon,and All roofC erin [O BClas$ rbetter.
hereby authorize represenlatives d this dry to enter upon the ebake-menibrred proparry,for In-
spaclbn Wrposas.
(We)agree to save,Inciemnlfy and keep harmless he Cly of Cupertino agBinet Ile tli
judgments,costs ane experses which may In any way accrue against said City In consequence SI ATU F APP CANT DATE
of
the grantiflg of this pemdt.
PRE-INSPECTION: PLYWOOD: IN-PROD ESS: '
INSP. DATE INSP. DATE 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: Tp: Rng: Sub: Elk: LOC:36935034.00
INVOICE DATE. . . ...: 10/06/1999
REFERENCE ID # . ..: 99100028
SITE ADDRESS . . . . .: 10690 MARTINWOOD WY
SUBDIVISION . . . . . ..
CITY . ......... . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER ....... . . . . .: OTT RANDY L
ADDRESS ..... . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4420
CONTRACTOR . . . . . ..: LIC 0
COMPANY .. . . . . . . ..:
ADDRESS . . . . . . . . .. :
CITY/STATE/ZIP . . . .
TELEPHONE . . . . . . . . :
FEE DESCRIPTION CHR TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPERMFEE P 117.00 0.00 117.00
BSEISMICRE P 0.60 0.00 0.60
_________ ____________ ___________
117.60 0.00 117.60
V.ID DESCRIPTION VOICE ID DESCRIPTION
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•
I
• CITY OF CUPERTINO
Item 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: nancyc
COPY # 1
Sec: Twp: Rug: Sub: Blk: Lot:36935034.00
DATE ISSUED... . . . . : 10/06/1999
RECEIPT #...... . . . : 10255
REFERENCE ID # . . . : 99100028
SITE ADDRESS . . . . . : 10690 MARTINWOOD WY
SUBDIVISION ... . . . .
CITY . . ......... . . : CUPERTINO
IMPACT AREA ...... .
OWNER . . . . ....... . : OTT RANDY L
ADDRESS . . ........ :
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-4420
RECEIVED FROM ... . . TIM
CONTRACTOR ....... : LIC #
COMPANY . ........ . :
ADDRESS . ........ . .
CITY/STATE/ZIP .. . . -
TELEPHONE ....... . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAD
BPERMFEE VALUATION 6,000.00 117.00 0.00 117.00 0.00
ICRE VALUATION 6,000.00 -0. 0.00 0.60 0.00
B*
TOTAL PERMIT 117.60 0.00 117.60 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 117.60 1044
------------
TOTAL RECEIPT 117.60
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•