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99100143 z o .ff) 100 ( PERMIT R_" APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION 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 i07- U ( fWI� I P.� ASI �(��`f RESIDENTIAL COMMERCIAL OTHER OWNER'S _ HAZARDOUS FIRE AREA ��•��l/'I t/� I/�n 1 I/� YES ❑ N yes I understand that a Class A NAME I� t v�Y �� I V V I/1 Yl roof assembly is repaired. �O V.2- Q15D �, / NO ❑ Initial I.C.B.O.A ADDRESS r-G/� EXISTING ROIIIF V PHONE IU/V �� I —Z NUMBER OF EXISTING COVERINGS CONTRACTIORIS � /1 ,� �-, ' TO BE REMOVED_ TO BE RETAINED NAME 'I ��{ ) r F EKING ADDRESS CITY s ZIP EXISTING NGQ -o� gel ��/� PHONE BUILT-UP ROOF LICENSE NUMBER ASPHALT SHINGLES gJV LICENSED CONTRACTORS DECLARATION I hereby affirm that I am llcenred uriaer prodsbns of Chapter B(commusexc g with section WOOD SHAKES J� ](00)of DMsedn 3 of the Business and Professions Code,and my license Is In full farce and - affect. WOOD SHINGLES ❑ License Clew Lie.Number_I.S�MZl Date - Contractor OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED hereby sftBu that am exempt from the e: Any or:enae Lew for the brewing reason. DL27 (Sec.]031.5,rumness end oRsh,Protocol"re Code: Arty city or county whkh requires a permit toconstruct,alley,Improve,tleme si or repeat eny structure,Is J to Its Issuance,also reproves the BUILT-UP.ROOFpplicant tr ouch permit to file a signed statement thea he la n Sect o pursuant to Na provof theof the Conireclors Lbense Law(Chapter B(commerdnB with Secibn]000)of Division 3 of theBusiness and Proleadona Cork)orthat he as exempt therefrom antl the beefs for the alleged ASPHALT SHINGLES exemption.Any violation of Secdon]031.5 by any applicant for a permit subjects the applicant toa civil penalty of not mora then five hundred dollars❑1.as omerol me property,army artgloyess with wages as Moir we rnmpensation,will do WOOD SHAKES the work,seed Ne stmcare is hour Intended or offered low sale(Sec.7044,Business antl Profen- 6ydons Code:The Contractors License Lew does not apply to an oamer N property win bullGs or WOOD SHINGLESMpro es thereon,end who does,such work h4nean a thrpgh his own employees.proveded stat such Improvements ere not Intended or offered for ode.II,however,the bulkllng or ImprovemanlIs add wthin ane year of completion,the awner4iuilder will he"the burden N proving mat fe did OTHER(SPECIFY) not build or Improve for purpose of ode.). ❑I,as owner of the property,am excludvety,contracting with licensed contractors to caneauct the project(Sec.]044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO. r apply to an owner of property who builds or Improves thereon,and who contracts for such projects with a Wrtractoge)licensed pursuant to me Contractor's License Lax. PROVIDE MFGR.INSTALLATION SPECS. ❑t son exempt under Sec. ,B 8 P.C.lour this reason Owner Deb WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under peralty of perjury one of the following declaration: I ((( I I 1 oO veend will ctinalna of the Late of Consent toself-insurefor of Me ComPohich Un, ( / /� �� Building l r az provided for by Section 00 of the LobarCode Consent thalednsure for Wod ws Com ampub is I//�J`, ILe/ (i P.mit Issued. Seismic IT laInsurance,as and will maintain Workers Compensation Insuraas required by Section 37W of Ig Me Lebon Code,for the pone, nce of the work for which this Permit la Issued,My Worker's Total k Compensetbn Insurance cartiar a��n--tlwwPolicy numbhr are. �y Canter Q" ML( wllcyNo.'�I�7 PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.C[] (This section deed net be manpletetl it the permit Is for one hundred dollars(SI(fa)or less.) I cedify,that b the pedormenc,of the work for which this permit is Issued,I shell not empl moy any person in any manner so as to become Babied th to e workrs m eCopensatin Laws oof car- All roofs shall be inspected prior to any roofing material being forma. installed. If a roof is installed without first obtaining an Date I Applicant' inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: It after meW g this CertB4cate of Exemption,you should became Applicant understands and will I with all non OIDt subject to the Workers'Compensation provisions of the labor Code,you must tonhwam mmpy PP comply y P with such providons or this permit shall be deemed rew W. Source regulations. I ce bly met I have read this application ON state that tie above Informallon is oorrect.I agree to mmpy with all pry and county ordinances and sate laws refetlrg to buYtling cormbucibn,she Allroot Bungs to class"C"or er. / hereby auO)Odze repreaer athes of tiro city to enter upon the ebove-mentloned property for In- / 1-1.( j✓/,/ spectlon purposes. (We)agree to save,Indemnify and keep harmless the Cry of Cupertino agmeat IlabIIWes, �. judgments,coca and expenses which may In any way accrue against said City In consequence 51 'NATURE OF APPLICANT DATE of the granting of this 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE CITY OF CUPERTINO BUILDING PERMIT INVOICE OPERATOR: kareub Sec: Twp: Rng: Sub: Blk: Loc:36942001.00 INVOICE DATE...... : 10/27/1999 REFERENCE ID N ... : 99100143 SITE ADDRESS ..... : 10261 MILLER AV SUBDIVISION ...... . CITY .. . . . ........ : CUPERTINO IMPACT AREA ...... . OWNER . . . . ........ : EMILIO ARELLANO ADDRESS . . ....... . : CITY/STATE/ZIP .. . : CUPERTINO CA, CA 95014-4327 CONTRACTOR ....... : KAHN, RUSSELL LIC # 17999 COMPANY . . ........ : CROWN ROOFING INC ADDRESS . ......... : 214 CRISTICH LN CITY/STATE/ZIP ... : CAMPBELL, CA 95008 TELEPHONE ........ : 14081369-7444 FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE --------------- --- --------- ------------ ----------- BPERMFEE P 187.00 0.00 187.00 BSEISMICRE P 1.30 0.00 1.30 --------- ------------ ----------- 188.30 0.00 188.30 VOICE ID DESCRIPTION VOICE ID DESCRIPTION ............................ ........ ---------- FAME 307 INSULATION b 1 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 603 ROOF BATTENS 604 ROOF IN-PROGRESS •