99080046•
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PERMIT
APPLICATION FOR CITY OF CUPERTINO NUIMBE
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408) 777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/
l 0 39r
/
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
HAZARDOUS FIRE AREA
YES ❑ If yea— I understand that a Class A
NAME
hoof "mar ably is required.
NO ClInibel I.C.B.O. if
EXISTING ROOF COVERING
lfl 3is'
ADDRESS c��o i
PHONE'
NUMBER OF EXISTING COVERINGS
(�
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS�,aA'�
7 '�// J
T/P F RING
CITY871P (�' ��/lam
EXISTING
77? ^ � 3 /
PHONE
BUILT-UP ROOF
3
LICENSE
z /'.
NUMBER (�
ASPHALT SHINGLES ❑ 76f
/J
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I can licensed under provisions of Chapter 9 (commencing with Section
WOOD SHAKES
7000) of Drisfon 3 of ane Business and Professions Code, aad my license Is in M force and
,
cited.
//� 3 2
"C- 3 -
WOOD SHINGLES ❑
Uceroe Class Lk. Number
Data 9
OTHER S �n
OWNER BUILDER
LDERD LLicense
PROPOSED D ILLL}S6S IIIIIJJJ= U
it=
hereby affirmu Mea am exempt Iron Me License Law for following reason.
(Sec. 7031.5, ,Impress ere e: Any city re
Code: Arty dry or county which requires a to
crosboct,or after, fish, or re unrest
eny mntrthat he is lorrollsaueainelsoregwres the
suImprove, demto file signed statementthat he le to the provisions
applicant for such permit m Ills a signed p
BUILT-UP FAUG 61999
hlicensedSection
r 0 (comm
tars Ucanse Lew (Chapter 9 (commenting with Section 7000) of
000) o 3 0l the
of theBusiness
ss and
Business entl for the
Coda) or that he a exempt Mer Iron entl the teals for the
ASPHALT GLES ❑
violation hunts Oyerry epplkan epermlt subjects the applicant to
scant to
aexemption.dirtearly fno;m re then
e ddl purely of ret more then live hudred dollars
C] 1. as owner of the property, or my empWyaes with gas as their We compensation, will do
WOOD SH ®�$_—.----
the walk, entl the structure is not Inicnde w off red I r sale Sec. 7044, Business and Proles
eons Codo: The Contractors Ucense L do not ply t n owner of property who bulitls or
roves Unclean, and who does auto sen I his own em
tap poyeee,provdetlthat
such Improvements are not Intended o o red for ala. r, the building or Improvement
WOOD SHINGLES ❑
is said within one year of completion,t eowrner- Ida 'I ova the burden of prating that he did
OTHER SPECIFY
not build or Improve for Purpose of sale.).
❑ I, as Owner of Me property, am exclusimly contracting with licensed contractors to consbruct
the project (Sao 7044, Boniness and Professions Code: The Contrectore License Lew does not
PROVIDE I.C.B.O. REPORT NO.
appy to an owner of property who builds or Improres thereon, and who contracts for such projects
with a contractors) Ifoansetl pursuant to the Contractor'a License Law,
PROVIDE MFGR. INSTALLATION SPECS.
I em exempt under Sec. ,B 6 P. C. for Mie wan
borer Data
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury, me of the following declaration:
I have and will maintain a Certhcale of Consent to self -insure for Workers Campemilon,7CP
Building
as provided for by Section 37W of the Labor Code, for the peeormill of Me work for which this
permit 0Issued.
Seismic T
0I have and will maintain Workers Co mpensatfon Insurance, as required by Section 3700 o1
the Labor Code, for the the for Is Issued. My Worker's
pedormence of work which this penman
Compensat Policy
101 2.76
TOlaf�
arpa ten rand number ere: Q r?y p
`�•Lfr r
PERMIT AUTHORIZATION
DATE
Cartier •Q �QG Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
Mks section need not be completed 8 the pernst Is for one hu tired dollars ($IN) or leas.)
I certify that In the pedormance of the work for which this permit is issued. I OaN net empty
All roofs shall be inspected prior to any roofing material being
any person In any manner so ea to become subject to the Workers' Compensation Laws of Cali-
fornla.
installed. If a roof is installed without first obtaining an
Date Appllceni /s�'z'- L�—>
inspection, I agree to remove all new materials for inspection.
Applicant understands and will comply with all non point
PP P Y P
.�
NOTICE t E APPLICANT: If, etler making th Certillceta of Exemption, you should Osteone
subject m Ore Workers Compensation pr s d the Labor Code, you muss forthwith empty
with such provisions or this Permit shell be deemed revoked.
source regulations.
I redly Met I have road this application and state that the above information Is correct.I agree
to comply with all city and count' ordinances and state laws relating to building convrucson,and
All roof Coverings to be class "C"or better.
hereby auCedze representatives of this city to anter upon the above-mentioned property for In.
spection purposes.
(We) agree to sere, Indemnify and keep hemgess Me Cary of Cupertino against RabWties,
wndh may in eM way some against Bele CGy In consequerpe
' oidgg me
TKWATURE OF APPLICANT /DATE
t7nt^W�o lMmit�
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
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
i
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: knrenb
Sec: Twp: Rug: Sub: Blk: Lot:34245017.00
INVOICE DATE......: 08/O6/1999
REFERENCE ID # ...: 99080046
SITE ADDRESS .....: 10395 MELISSA Cr
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: GLOCKLER HERRMANN C AND HILTRU
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-2620
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0
CONTRACTOR .......:
WAGNER, SCOTT R LIC # 12594
COMPANY ..........:
WAGNER ROOFING CONTRACTORS INC
ADDRESS ..........:
12242 SARATOGA-SUNNYVAL RD
CITY/STATE/ZIP
...: SARATOGA, CA 95070
TELEPHONE ........:
14081777-8331
FEE DESCRIPTION CHK
TOTAL FEE PAID -TO -DATE BALANCE DUE
---------------
BPERMFEE
---
P
--------------------------------
167.00 0.00 167.00
BSEISMICRE
P
1.10 0.00 1.10
--------- ------------ -----------
168.10 0.00 168.10
ID
DESCRIPTION
ICE
-0307 ID SCRIPTION
FRAME ............................
INSULATION
601 ROOF
TEAR OFF
602 ROOF PLYWOOD NAIL
603 ROOF
BATTENS
604 ROOF IN -PROGRESS
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0