99090034 �• ' 3� G -21 — OS Z PERMIS-�
APPLICATION FOR CITY OF CUPERTINO NUMBER —
INSPECTION
—
INSPECTION DIVISION PERMIT ExPIRATI N
REROOF PERMIT (408)TT7-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ M yes-I understand Mat a Class A
NAME roof I1a5,=*Y Is requlred.
NO ❑ Initial I.C.B.O.R
ADDRESS EXISTING ROOF COVERING
PHONE pc 5-3 —OF 7k NUMBER OF EXISTING COVERINGS ,
CONTRAC 'S f
L` TO BE REMOVED r TOB ETAINED I
NAME
ADDRESS / F
cin a z//IPy3 0 EXISTING GI(,�- (/
PHONLL d 77 —07D 7 BUILT-UP ROOF 2/4 G
LICENSE p
NUMBER .�S S ASPHALT SHINGLES ❑ /" /
LICENSED CONTRACTORS DECLARATION .-.
I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES I 4-1: Q
7IX10)of DMskm 3 of the Business and Profevsdne Code,and my license Is In full force and L
effect.
S WOOD SHINGLES �y ❑
Date Contractor
Clens Lk.Number y SEP
Date 9�
9 �f OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATI PROPOSED By
hereby affirm that am exempt from the e: Any
License Lew forme followingreason.
(Sec.7031.5,Business and olish,ebnv Code: Any clly pr county which requires,able a perms to
construct,alter,imprma,demolish,orrepair any nt that he
prior to Its LcwsuantetxeeprWalthe BUILT-UP ROOF
of theCtbrsuch permit to hie(Chat statementthathe Ieh ectio pursuant alpr 3 of the
. d the Contractors License Lew(Chapter h Is ex commencing t with Section 7000)al Dfor Me 3 of the
exemption.
entl Pmtevloru Cade)or met he la exempt therefrom and the baste for ma alleged ASPHALT SHINGLES
exemption.Arcot o t mo of Section 7031.5 by any eppllcent for a permit eub)Bcty the applicant ro
e clWl pertelly of not more than flue fkrrdretl dollen
❑I,as owner of the property,or my,employees with wages as Meir We compensation,will do WOOD SHAKES ❑
the work,and the structure IS not Intended or offered for sale(Sec.7044,Bualneee and Profes-
elonsCode: on
The Contractors License Lew does rot apply to an owner of properly who builds or WOOD SHINGLES El
there ,and who does Such work himself or through his own employees,provided that
such Improvements are not Intended or maned lar vele.If,however,the building or Improvement y e D
Is sold within one year of completion,me owner-builderwal have We burden of proving that he dm OTHER(SPECIFY) ❑
not bulk!or Improve for purpose of sale.).
01,as owner of the property,em exduaveiy contracting with licensed contractors to construct
the protect(9x.7044,Buelnaee and Profevvlons coda:The Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of properly who builds or Impro sthereon,and who contracts for Such protects
with a cornraaor(e)licensed Pursuant to me Contractors License Law' PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B f P.C.b Ihle reason
oNOefDate APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECIARATION
I thereby affirm under Penalty of perjury we of me following declaration:
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensation, BUlldln
as provided for by Section 3707 of the Labor Code,for the performance of the wank for which MIS 2 If / g
Permit Is sawed. - /// // ��(I S- Seismic
have and will maithe tainperformance
Worker's f the work
InSu h this as repulsed by S.My 370001
the or Code,for the performance of the work for which this perms is IeSum.My Workers
Compensation re or ar jFolfcy number are: Total
Canler�AcCi—Z;2_� Policy No. ' 3 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[] -
(This sectionneed not be compleletl II the permit Is fur one hundred tlollere($1 W)or lees.)'
cenlfy that In me performance of Me work for which this permit is Issued,I all not employ
any person In a manner So as to become subject th rkers'Compen ellen Lawn of Caw All roofs shall be inspected prior to any roofing material being
tomid. installed. If a roof is installed without first obtaining an
Date AQpNcam inspection,I agree to remove all new materials for inspection.
SWto NO E t IPUCANT. It, klr
,after mag the Camry a fof Exemption,you ahead become
Compeneatlon provieicnS of the Labor Cotle,you must forthwith comply Applicant understands and will comply with all non point
with such pravivlma or this penult Shell be deemed revoked. Source regulations.
I corny that I hese read this application and state that the above Information Is correct.I agree
to comply with all city and county colnancas end state Tawe rotating to building construction,and All roof Cover gs Class u r better.
hereby eumorize representatives of this city to enter upon the above-mentioned property for In-
spoil purposes.
(We)agree to save,.Indemnity and keep harmless the City of Cupertino agelnal IleblIft es, - -
o Ne grrantingg costs h s expenses
s wh{ch they In any way accrue against Said Clry In coneeeuence SIGNATURE OF AYPLICAiTT 15ATE
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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CDPERTINO
• BUILDING PERMIT INVOICE OPERATOR nancyc
Sec: Twp: Rng: Sub: Blk: Lot:31621052.00
INVOICE DATE...... : 09/03/1999
REFERENCE ID # ... : 99090034
SITE ADDRESS ..... : 10135 MC LATIN PL
SUBDIVISION ..... . .
CITY .. . . . . . . ..... : CUPERTINO
IMPACT AREA . . . ... .
OWNER .. . . . . . . . ... : LEE HOWARD AND CHANG WENDY
ADDRESS . . . . . . . . .. :
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-2335
CONTRACTOR . . . . ...: LIC #
COMPANY .. . . . . . ...:
ADDRESS .. . . . . . ...:
CITY/STATE/ZIP ... . ,
TELEPHONE ... .. ...:
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
V ID --_ DESCRIPTION__-_--_-- VOICE ID _ DESCRIPTION
... .... ........ ......._ "..ee ...........�.
3 S FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•
CITY OF CUPERTINO
2 of 2 BUILDING PERMIT RECEIPT OPERATOR: nancyc
COPY q 1
Sec: Twp: Rng: Sub: Blk: Lot:31621052.00
DATE ISSUED....... : 09/03/1999
RECEIPT 4. ........ : 9982
REFERENCE ID q ... : 99090034
SITE ADDRESS .... . : 10135 MC LAREN PL
SUBDIVISION .... . . .
CITY . . . . ...... . . . : CUPERTINO
IMPACT AREA ... . . . .
OWNER . . ......... . . LEE HOWARD AND CHANG WENDY
ADDRESS ........ . . :
CITY/$TATE/ZIP . . . : CUPERTINO CA, CA 95014-2335
RECEIVED FROM .. . .: TIM
CONTRACTOR ... . . . . : LIC q
COMPANY ....... . . . .
ADDRESS ...... . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE ...... . . :
FEE TO UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW DAL
BPERMFEE VALUATION 9,000.00 147.00 0.00 147.00 0.00
BSEISMICRE VALUATION 9,000.00 0.90 0.00 0.90 0.00
---------- ---------- ---------- ----------
?PERMIT 147.90 0,.00 147.90 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 295.80 10206,
------------
TOTAL RECEIPT 295.80
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
•