99090099 3S—ze 07 00 (,� 9 oa
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION REMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 18D DAYS OF PERMIT ISSUANCE OR
18DDAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
R'S C Ile fill RESIDENTIAL COMMERCIAL OTHER
HAZARDOUS FIRE AREA
ll
NAME T� lJl - - YES ❑ If yes—I understand that a ClaartYYy ssA
_ roof assis required.
NO ❑ Inlbal I.C.B.O.A
ADDRESS 5 '� VVl EXISTING ROOF COVERING
• PHONE lo
NUMBER OF EXISTING COVERINGS
CONITR TO ' - /'•�
TO BE REMOVED TO BE RETAINED (•,�
NAME
ADDRESS - - TYPE OF ROOF
CITY&ZIP 171 EXISTING
PHONE_ ? *_ /A33'a 33 g�3 BUILT-UP ROOF �/
NUMBER 7 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby efllrm that I am Ilcensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7(00)of DMalon 3 of the Business anti Professions Code,end my liens Is In full force arrtl
affect. e, q/y� WOOD SHINGLES ❑
Ucarl Cl eee 1..�.L� Dc.Number
JASPHSHINGLESS,
FY)—""u 0
Date Can anar
OWNER-BUILDER DECIARAMON I hereby affirm that I em exempt from the Contractor's Ucenae Lew for the Idlowing reason. —`�(Sec.7031.5,Business end Professions Cade: Arty city or county which requires a permit to
canetrl after,Improve.demolish,or repair any structure,prior to hs lssuerwa,else requlres Na F 1 1999 0`
eppllent for each permit to Nle a signed statement Net ha H licensed Pursuant to the Provlebruof the Centrectofe Uce.Law(Chapter 9(cammenclnp with Section 7000)of Division 3 of tiro � ❑Bualrww and ProfessionCode)or that he Is exempt therefrom end the basis for the allegetl exanption.Any ioLatlon of Section 7031.5 by any applicant for a permit subjects the applicant to
a CMI penalty of not more man Nva hundred dollars(5500).):
❑I,es owner of the property,or my employees with wages as their sob compensatian,will do Sthe work,and the structure la not Intandetl or offeretl for sale(Sec.7044,Business anti Plates-
slots,Code:The Contractor's License Law does not apply to an owner of property who builds or WOOD SHINGLES ❑
Improver,thereon,and who does such work himself or through his own employess, rodded that
smh Improvements are cwt Intended or offered for sale.If,however,Me building or Pmplavarnent '
N on
sold will e year of competbth
n, e owmwr-pNlder will hove the burden of proving that he did OTHER SPECIFY
not build or Improve for purpose of sab.). ( )
❑I,as owner of the properry,em exduslvely cantrectlngwith licensed contrcaore to construct /`//�
the project(Sec.7046,Business and Professions Coda:The Contractor's License Idoes not PROVIDE I.C.B.O. REPORT NO. "! 49
apply to an owtwr of property,who builds or imprmes thereon,arra who contracts for such projects
MM a contractor(s)licensed pursuant to the Contractors Uceee Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 6 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 following declaration:
I have end will maintain a CertNlcate of Consent to self-Insure for Worker's Compensation, Building
es provided for by Section 3700 of the Labor Code,for the performance of the worn for which this
permit Is Issued.
k
711 have arta will maintain Worker's Compensation Insurance as required by Section 3700 of Seismic
r the Labor Code,for the performance of the work for which this permit U Issued.My Workers 70t7 Total / 7R.
LL/
Compensa n Insurance tartlet end cy number/ere: {,_n �}
Carrier, rle7fe4'1'1 A4 eo4WcY A132��'3�l PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.o.l]
(This secllon need not be completed If the permit Is for one hundred!dollars($1 W)or less.)
I certify that In the performance of Me work for which Nle permit Is Issued,I shell not ampby
any person In any manner w as to became subject to the Workers'Compensation Lowe of Cel4 All roofs shall be inspected prior to any roofing material being
fornie. installed. If a roof is installed without first obtaining an
Date Appllent inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: If,after making this Cerfircete of Exemption,you should became Applicant understands and will comply with all non point
subject to time Workers'Compensation pro rslons of the Labor Code,you must forthwith comply
with such provislons or thle permit shell be deemetl re+oked. source regulations.
I ceRty that I he"reed Nu appikatlon and stale that Nie all Information Is correct I agree
to campy with all city and county ordinances and atate tawa relepng to bullang construction.and All roof Co sto be cls or better.
hereby authorize representatives of Nis city to enter upon the above-mentioned property,for In-
specdon puree e
gmel agree to save,Irma w and keep hermleea aro City of Cupertino against liabilities,
ence f
of me gnts,caeb and pernrl es which may In any way a¢rue against ealtl City In cars,aquence
of the granting of NW parmlt. SIGNATURE OF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
If DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: - FINAL:
If DATE INSP. DATE INSP. ' DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
CITY OF CUPERTINO
1 of 1 BUILDING PERMIT RECEIPT OPERATOR: christye
COPY N 1
Sec: Twp: Rug: Sub: Blk: Lot:35607006.00
DATE ISSUED. ......: 09/15/1999
RECEIPT 4. . . ......: 10079
REFERENCE ID # ...: 99090099
SITE ADDRESS ..... : 22204 MC CLELLAN RD
SUBDIVISION ...... .
CITY .......... .. . : CUPERTINO
IMPACT AREA ... . . . .
OWNER ............ : CHRUN G
ADDRESS .......... :
CITY/STATE/ZIP .. . : CUPERTINO CA, CA 95014-4061
RECEIVED FROM .. . . : TIM
CONTRACTOR .... . . . : RADONICH, GARY LIC b 17814
COMPANY .. . . . . . ...: LOS GATOS ROOFING
ADDRESS .... . .....: 1771 SMITH AVE
CITY/STATE/ZIP ...: LOS GATOS, CA 95030
TELEPHONE ........: (408)358-1233
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW DAL
__________ _____________ ____ __-----___
HPERMFEE VALUATION 12,000.00 177.00 0.00 177.00 0.00
HS SMICRE VALUATION 12,000.00 1.20 0.00 1.20 D.00
PERMIT : ____178 20 0.00 178.20 0.00
METHOD OF PAYMENT AMOUNT NUMBER
------------ - _
CHECK 178.20 178.20
------------
TOTAL RECEIPT 178.2D
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
•
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE 'INVOICE INVOICE
CITY OF CUPERTINO
. BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: Rng: Sub: Blk: Lot:35607006.00
INVOICE DATE...... : 09/15/1999
REFERENCE ID # ... : 99090099
SITE ADDRESS ..... : 22204 MC CLELLAN RD
SUBDIVISION ...... .
CITY ............. : CUPERTINO
IMPACT AREA ... . . . .
OWNER ....... . . . . . : CHEUNG
• ADDRESS ...... . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4061
CONTRACTOR .... . . . : RADONICH, GARY LIC N 17814
COMPANY LOS GATOS ROOFING
ADDRESS ....... . . . : 1771 SMITH AVE
CITY/STATE/ZIP . . . : LOS GATOS; CA 95030 .
TELEPHONE .... . . . . : (408)358-1233
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPERMFEE P 177.00 0.00 177.00
BSEISMICRE P 1.20 0.00 1.20
--------- ------------ -----------
178.20 0.00 178.20
VID ---.e= DESCRIPTIONVOICE ID DESCRIPTION
.........-------' ........ --------- ...............
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•