99080107 ( 2 D (` qQ0/07
PERMIT
_ .. APPLICATION FOR CITY OF CUPERTINO NUMBER R—
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408).M-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 ❑ If yes—1 understand That a Class A
NAME roof assembly is required.
NO ❑ Initial I.C.B.O.N
ADDRESS
EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS D
CONTRACTOR'S
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS ���ytrz� �� / 0 OF 0ERIN
CITU BZIP ! �JJ / /Y'V [_ C7
l — / EMTING
PHONE V/ BUILT-UP ROOF O/
LICENSE ( /
NUMBER 3 ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
- I hereby'efllrm that I am licensed under prwlslons of Chapter 9(commencing with Section WOOD SHAKES
7000)o/Dldslon 3 of the Business and Professbns Code,and my license Is In fu ce end
effect.
3 WOOD SHINGLES
License C es Lk.Number �
OTHER(SPECIFY) Q "
Dat - Cmtmgtar U
OWNEFFBUILDER DECLARATION PROPOSED PUG
I hereby affirm that I am exempt from the Contractors License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any any or county which requires a permit to
canUtah,alter.Improve,centralist,or repair my structure,prior to its Issuance,also requires the BUILT-UP ROOF
applicant for such permlt to We a signed statement that he Is licensed!pursuant to the prxwlebre Q
of the Contractors Uterine Law(Chapter 9(comemncin wIN Section 7000)of Dhisian 3 of the
Business and Professions Cade)or that he is exempt therefrom and me heals for the alleged ASPHALT SHINGLES Py
oxemption Any violation of Section 7031.5 by any applksnt for a Permit subjects the apPllcant to
e civil penally of not more than five hundred ddlars($500).): '
❑I,as owner of the property,or my employees with wages as their sok comparnatian,wild do WOOD SHAKES
El
the work,end the structure is not intended or offered kr We(Sec.7044,Business arta Proles.
sister Code:Tho Contractors License Law does not appy to an owner of property who(wilds or WOOD SHINGLES
improves therom,and who does such work himself or through his own emplanes,provided that El
such Improvements are not Intended or offered for side.It,however,the building or improvement
Is add wiwn me year of completion,the owner-builder will have the burden of proving that he did OTHER(SPECIFY) Q
net W lld or Improve for purpose of sale.).
I,as owner of the property,am excivavely contracting with licensed contractors to construct
the Protect(Sec.7044,Business and!Prolesslons Cade:The Contractors License law time not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who bulks or Improves therein,antl who contracts for such projects
with a contractor(s)licensed pursuant to tiro Contmaors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exempt under Sec. a 8 P.C.for Nis reason
O.vner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the Wowing declaration:
I have and will maintain a Certificate of CmPmt to sell-Insure for Workers Campsnsatkn, Building
as provided for by Section 3700 of the Lobar Case,for Ute perkrmaroe of the work for which Nle
Permit is issued. O U � Seismic
❑ have and will themaintain Workers f the work
Insurance,as required Is l by Section im of
the Leber Code,for the performance of the rvrk for which this permit Is Issuetl.kt1'Workers
Competence cgrder qpl Pollcypymber are: ^�O Total
Carder -r(CE CERTIFICATE
EX/ FROM o. Y PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSARONINSURPNCE N.C.I]
(Thar section need hot lbs completed II the parent Is kr we hunered collars($100)or leas.)
I certify that In the performance of the war,for which this permit Is Issued, shell ret employ
any person In any member so as to become subject to the rkers cam ashen Laws of can- All roofs shall be inspected prior to any roofing material being
fame. installed. If a roof Is Installed without first obtaining an
Date / ° Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making ra Certificate of Exemption,you should become
subject to the Workers'Compensatbn provisions of the Labor Code,you must foBwrilh comply Applicant understands and will comply with all non point
with such provisions or fhb parent shall be deemed revoked. source regulations.
I amity that I have read this application and state that the above Information Is correct.I agree
to comply with all city end county Ordinances and stale laws relating to Wilding Xampl uction,and �IIlDBf-C g be class'B or better.
hereby auffern representatives of me city to enter upon the above-mentioned property for In-
Reaction purposes,
(We)agree to save,Indemnity and keep harmless the City of Cupertino against Iladlltlee,
ledgmints,costs antl expenses which nay in any way accrue against sad City In consequence
of the to of this permu. W11ATURE OF APPLICANT DATE
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: yvonnek
Sec: Twp: Rng: Sub: Blk: Lot:36919041.00
INVOICE DATE...... : 08/16/1999
REFERENCE ID # ... : 99080107
SITE ADDRESS ... . . : 869 MILLER AV
SUBDIVISION . . . . . . .
CITY . ...... . . . . . . . CUPERTINO
IMPACT AREA . . . . . ..
OWNER ..... . . . . . . . : YEE EDDIE L AND CHRISTINE S TR
ADDRESS .. . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1320
CONTRACTOR . .. ....: LIC #
COMPANY .. . . . .....:
ADDRESS . . . . . .....:
CITY/STATE/ZIP ... . ,
TELEPHONE .. ...... :
NOTE: THE FEES LISTED ARE ONLY THOSE DUE BEFORE PERMIT PRINTING
FEE DESCRIPTION CHR TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPERMFEE P 117.00 0.00 117.00
BSEISMICRE P 0.60 0.00 0.60
--------- ------------ -----------
117.60 0.00 117.60
VTO _--._ DESCRIPTION - VOICE IO __--..-.DESCRIPTION
7------.-..ea -------- --------------
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS