99080071PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
L° INSPECTION DIVISION PERMIT EX t n N
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
�2_13 S F 221e2t._�
-
RESIDENTIAL -1= COMMERCIAL OTHER
OWNER'S /
HAZARDOUS FIRE AREA
yy� ��
YES [3=- lunlferstard1 that a Class
NAME l[[
ssembly is required.
140 ❑ Inlbal I.C.B.O.:1
. -
5/a ry/�o_�
EXISTING ROOF COVERING
ADDRESS
7,J 6 — 0 SS
NUMBER OF EXISTING. COVERINGS /
PHONE b
CONTRACT S
'
TO BE REMOVED 10ZejdTAINED
NAME l
alTl�)�f.^' /�/��–��/�/1 /j p�. /��
ESS
ADD
RB
/ TYPE OF RO
CITY P 7.�/
EXISTING
/
PHONE `650,.-i%.3 -"637.3
Q
BUILT-UP ROOF
LICENSE
NUMBER 4/ff;2--7 00
ASPHALT SHINGLES ❑
-
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provlsiom of Chapter B (commandng with Section
7000) of Division 3 of the Business and Prolesskxs Code, and my license Is In lud force and
WOOD SHAKES
effect.
,
Lkarree Clave � 3 9� Lk. Number Z
WOOD SHINGLES
D
Date / ; 9/ r Gantrector
OTHER (SPECIFY)
ARID n
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from Ne ComnscloYe License Law for the 1°llo ving reason.
PROPOSED.
(Sec. 7031.5, Bualness and Professions Code: Any city or county which requires a permit to
construct, after, Improve, damollsh, or raider arty structure, prior to its Issuance, also requires the
BUILT-UP ROOF
applicant for such permit to No a signed statement that he Is licensed pursuant to me pro islons
of me Contractor's License Law (Chapter B (corrvnendrq with Section 70X) of Division 3 of the
Business and Professions Code) or that he Is exempt lharefrom and the basis for the alleged
exompt on. Any Wolatlon of SecLbn 7031.5 by any applicant for a permit subjects ma applicant to
ASPHALT SHINGLES
e CMI penalty of not more then five hunched dollars (SSX)t:
1, the as
WOOD SHAKES ❑
CI as owner of property, or my employees with wages their sale compensator, will do
the work, and the structure Is not Intanded or offered for sale (Sac. 70", Buelnaee and Profss-
ebnsCode :The ContractoesUp nas Low domnot apply toanownerofproperty who Witte or
WOOD SHINGLES ❑
Improvee thereon, end who does such work himself or through his own employees, provided that
such Improvaments are not Intended or offered Ion sale. If, however, me bulWing or Improvement
Is
1.✓/�
sold within one year of completlon, the owner -Wilder will have the burden of proNng that he did
OTHER (SPECIFY) El!
not Wild or Improve for purpose of sate.).
❑ I, as owner of me property, am exch seely conthIcting with licensed contractors W carsuuct
the project (Sec. 7044, Business and Profmalons Code: The Contractors Ucense Law does not
'
PROVIDE I.C.B.O. REPORT NO.
appy to an owner of property who W Ilds or Improves maroon, and who comrade for such projects
wlm a contractor(a) licensed pursuant to the Contractor's License Law.
❑ I am exempt weer Sec. ,B & P. C. for mIa reason
PROVIDE MFGR. INSTALLATION SPECS.
Omer Data
WORKER'SCOMPENSATION DECLARATION '
APPLICATION DATE
VALUATION
PERMIT FEE
O
Building �
I hereby affirm under penalty of perjury one of the following tledaratlon: '
❑ 1 have and will maintain a Centlloete of Consent to self -Insure for Worker's Compensation,
as provided for by Section 37X of the Labor Code, for the pedormance d the work for which rotsIs
par^
^y/ QQ
J10 �77
O6
��, ��V /
'
Ihil end
br f Iwhikhmils
Q
SEISMIC
If�ieinpseirformadrwars miters
tM LaborCCotl°de, Me work for pporrequired
mmit bl issued, My Workers
Compeneatkm In rents carrier nit Policy number are: c�a
Mi �- � ' � —1 >
TOtak � k ..3 n
PERMIT AUTHORIZATION
DATE
carrier Policy N fz
- CERTIFICATE OF EXEMPTION FROM YORKERS'
COMPENSATION INSURANCE N.CQ
(This section need rot be completed 1r' the permit Is for ars hundred dollars ($100) or less.)
I certify mat In the performance of the work fa which this permit la Issued, I shall not employ
.any person In any manner m as to become subject to me Worker' Compensation Laws of Call.
All roof^ shall be inspected prior to any roofing.materialbein
rorMs.installed.
l
If a roof is installed without first obtaining an
Date o 9 Applicant
inspection, I agree to remove all new materials for inspection.
gIf, this after
Exemption, uentlb o�suect to me TO
orkas'Compenuon provision of Labor Coda,twim
Applicant understands and will comply with all non point
with such provisions a this permit shapbe deemed revoked.
Source regulations.
I certify mat I have read this application and state that the above Information le correct. I agree
to comply with all rely and county ordinances and stale Imva relating to construction, and
All roof coverings to be class "C" or better
hereby authorise represenstives of role city to enter upon the above-mentbnetl property roc In.
antling dproperty
apepurposes.
(We) veva,
(Wa) apse keep harm see the Clry Ct Ilebllitles,
and
toes In Clryin
SIGNATURE O APPLICANT DATE
yagainstcon
s expenses ai
and expersae which Trey any way amus against ealtl coneaquenu
mid
of Me gran
of ®e prentirg of role 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
OFFICE COPY
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Tp: Rng: Sub: Blk: Lot:32644017.00
INVOICE DATE......: 08/10/1999
REFERENCE ID k : 99080071
SITE ADDRESS .....:
21358 METEOR DR
SUBDIVISION .......
CITY .............:
CUPERTINO
IMPACT AREA .......
OWNER ...... ......
: TSAI DAN W AND STEPHEN S
ADDRESS ..........:
CITY/STATE/ZIP ...:
CUPERTINO CA, CA 95014-1324
CONTRACTOR .......:
COSMOS, RICHARD LIC # 18844
COMPANY ..........:
COSMOS ROOFING
ADDRESS ..........:
450 SAN ANTONIO RD
CITY/STATE/ZIP ...:
PALO ALTO, CA 94306
TELEPHONE ........:
(415)493-6373
FEE DESCRIPTION CHK
BPERMFEE P
BSEISMICRE P
VOT E ID ---- DESCRIPTION
,t - ME
. FRA •••--
601 ROOF TEAR OFF
603 ROOF BATTENS
0
TOTAL FEE PAID -TO -DATE BALANCE DUE
--------- ------------ -----------
187.00 0.00 187.00
1.30 0.00 1.30
--------- ------------ -----------
188.30 0.00 188.30
VOICE IDDESCRIPTION
........ ............................
307 INSULATION
602 ROOF PLYWOOD NAIL
604 ROOF IN -PROGRESS