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PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERM EXP1RanoN
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IFWORK ISNOT STARTED
WIWITHIN F DAYS PERMIT ISSUANCE OR
DAYSSFROM LAST CALLED INSPECTION.
BUILDING ADDRESS �� p
RESIDENTIAL - COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
VES ❑ Ifyes–IlmdarswMttata CleseA
NAMEk(i( "^^'7/7 roof asiambly is required.
NO ❑ Initial I.C.0.O.7
ADDRESS ////• EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS /
CONTAACTO 'S
TO BE REMOVED ` TO BE RETAINED Q
NAME
ADDRESS �_ ,/ �Q TYPE OF ROOF COVERING
CITY 8 ZIP [ v�
S NG
PHONE BUILT-
33 7 / BUILT-
UP ROOF ❑
LICENSE
NUMBER _ 3 1 ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licermpd under p ovisleas of Chapter 9(commanding with Section O HAKES CE3
7000)of Dlvison 3 of Ne Business part Professdne Corte,anti my license Is In full force aM e"�' C3 HINGLES License Clew Uc.Number rFY)Date Contractor THE ECIOMER-BUILDER DECLARATION1 hereby affirm that I am exempt nom the Contractor's License Law for the folkrwing reason. PROPOSED(Sec.7031.5,Business anti Proleselons Code: Any city or county which requlres a permit to
construct,after,Improve,demolish,or repair any structure,prior to its Issuance,also reQuires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
oI the Corneal Ucense Law(Chapter 9(commerho ng with Section 7000)of Division 3 of the _
Business and Professions Cada)or that he is exempt therefrom and the bests for the alleged ASPHALT SHINGLES
exemption.Any vblallon d Section 7031.5 by any applicant lora Permit subjects the applicant to
a civil penalty of net more Man five hundred dollars($500).):
❑i,aeownerof Maprop",,ormyemployee thwagesea Msasdecanpenseton,willdo WOOD SHAKES ❑
the work,end the structure is not intended or offered for sets(Sec.7044,Buelness and Pal
pore Coda:The Contractor's License Lew does rot apply to an owner al property who Wide an WOOD SHINGLES ❑
Improves thereon,and who ticee such work htni a through hLa own employees,provided that
such Improvements are not Intended or offered for sate.Il,however,the Witching or improvement
Is sold within cop year of compte,lon,the owner-0lder will have the burden of proving Met he did OTHER(SPECIFY) ❑
not bund or Improve for Purpose of eels.).
❑I,as owner of the property,am exdusi ey cnn,rscfing who licensed contractors to construct
the proled(Sec.7044,Business and Professions Code:The Contractor's License Law does rot PROVIDE I.C.B.O.REPORT NO.
appy to an owner of properly who builds or improves thereon,and who contracts for such emIods
with a conimctodej licensed pursuant to the.Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
I am exempt under Sec. ,B S P.C.for this reawn
owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION -
I hereby affirm under penalty of perjury one of the IdtoWng declaration:
I have she will maintain a Certificate of Consent to sell-insure for Workers Compensation, Buildin
as provided fon by Sedlon 37DO of the Leber Code,for Me parbrmarrce of the work for which Ws q Z' g
Permit Is insure. I
❑1 have and will maintain Workers Compensation Insurance,as required by Section 37W of Seismic '
90
the Labor Coda,'for the performance of the work for which this permit Is Issued.My Workers 7 O
Coni do Insurance canis d PoI number are: / Total
Carrl.,v +7n1T�7 Pat iq Na. ` ZO� `� PERMIT AUTHORIZATION DATE
k/ CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSAnCN INSURANCE N.CQ
(This unction need rot be completed If the permit is for one hundred dollars($10()or less.)
I catty that In the performance of this work for which Me permin is issued,I shall not employ
any person In any manner so as to become subject to the Works 'Compensation Laws of Call- All roofs shall be Inspected Prior to any roofing material being
fame. - installed. If a roof is installed without first obtaining an
Date Ari:loan, inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after seeking MIs rtlflcate of Exemption,you should become Applicant understands and will comply with all non Dint
subject to Ma Workem'Compenamlon provisions of the Labor Code,you must forthwith coon PP P Y P
with such provisions or MIs permit shall be deemed revoked. source regulations.
I cerl that I have read this application aro state Mat the above Information Is correct.I agree
to campy who all city and county ordinances and state laws relating to bulking construction,aro All roof Ver g, to be class"C"Or better.
hereby authorize representatives of this city to enter upon the above-mantoned property for In-
spection purposes.
(We)agree to save,Indemnify aro keep harmless the City of Cuparhro against Iledlltds, _
ludgmems,costs aro expenses which may In arty way,accrue against as Gy b coneaquenca IG URE O APP NT DATE
of the granting of MIs permit.
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
OFFICETCOPY
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: nancyc
Sec: Twp: Rng: Sub: Elk: Loc:32627033.00
INVOICE DATE. . . .. . : 08/23/1999
REFERENCE ID # . .. : 99080170
SITE ADDRESS . . . . .: 10100 MARY AV
SUBDIVISION . . . . . . .
CITY ...... . . . . . . .: CUPERTINO
IMPACT AREA . . . . ...
OWNER ..... . . . . .... AVERY ET AL
ADDRESS ... . . . . . . .:
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-1502
CONTRACTOR . . . . . . . : FOLK, DIETER LIC W 20389
COMPANY . . . . . . . . .. : OLD COUNTRY ROOFING
ADDRESS . . . . . . . . .. : 387 UMBARGER RD
CITY/STATE/ZIP ... : SAN JOSE, CA 951112055
TELEPHONE . . . .....: (408)362-1111
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPERMFEE P 147.00 0.00 147.00
BSEISMICRE P 0.90 0.00 0.90
--------- ------------ -----------
147.90 0.00 147.90
'E ID ------_ DESCRIPTION--_-_-___ VOICE ID -'_-DESCRIPTION
.--------- -------- ---- --------------
'05• FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•