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99100052 3s - oa -03 Cn 10 o 0 s oZ PERMI APPLICATION FOR CITY OF CUPERTINO NUMBER INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408) Tn-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR oil 180 DAYS FROM IAST CALLED INSPECTION. BUILDING ADDRESS RESIDENTIAL_ COMMERCIAL OTHER OWN //'' HAZARDOUS FIRE AREA NAME �y" CC�ru''c - VES ❑ If yes—I understand that a Class A roof assembly is required. Initial I.C.B.O.tl J ADDRESS`� /''r r� (�[ C� . EXISTING ROOF COVERING PHONTNpEprq'�7q NUMBER OF EXISTTINNG��C,IO�VEERINGS / E '.y}U ' ��C��v� t \GG�S _ 1' �� .. TO BE REMOVED "��TO AINED ADDRESS 2 / `` 1 ` (((/// `10-�•J� CC::--••�� ROOF CITY&ZIP'26p�w+�V�T/I w/'�� eil EXISTING - PHONE L �O O , ( 7 / e2l/ BUILT-UP ROOF LICENSE NUMBER C-/ 5' 2 ASPHALT SHINGLES ❑ y LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provlelane of Chapter B(commencing with Section WOOD SHAKES 1000)of DMsbn 3 of Me Business and Professions Code,and my license Is In full force and effect. _ �lO l� WOOD SHINGLES '❑ Ucense Clew Lic.Number Datil"// S,� 'contractor car u✓ OTHER (SPECIFY) '❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm IMI I am exempt from the Cpntrecfars License Law for the fohowing reason. (Sec.7031.5,Business end Profess'ans Code: Any city or county which requires a permit to construct.alter,Improve,demolish,or repair my structure,prior to Its Issuance,else requires the BUILT-UP ROOF applicant for such pens t to file a Signed statement that he Is Ikermatl pursuant to the provl of Me ConVeotore Ucenee Law(Chapter B(commencing with Section I(W)of DMslon 3 of the Business and Professions Code)or that he Is exempt therefrom and Me castle for the sMeged ASPHALT SHINGLES D exemption.Any vitiation of Section 7031.5 by any applicant for a penntl Subjects the applicant to D a civil Penalty of not more than flue hundred dollars(5500).): ❑I,as owner of the property,or my employees with wages as Meir sole compuneatlon,will do WOOD SHAKES u�'T 111999 the work,entl the structure is not intended or offered for sale(Sec:1044,Business entl Profes- stone Cade:The Contractor's License Lew does not apply to an owner of property who Wlkle or WOOD SHINGLES ❑ Improves thereon,and who open writ work himself or through his own employees,provltleo that succi Improvements are not Intended or Offered for sale.If.hovrever,Me Wilding or improvement Is sold within one year of completion,the ovmerWlfoer will have Me WrAen of proving that he diol OTHER(SPECIFY) ❑ not Wild a Improve for purpose of vele.). BY ❑I,as owner of the property,em excluslwfy contracting with kensed confiactom to constnrct the project(Sao.IOM,Business and Professions Code:The Contractors License law does not PROVIDE I.C.B.O.REPORT NO. apply to an owner of property who builds or Improves trw eon,arhtl wW contracts for writ projects with a contrador(s)licensed pursuant to the Contractors License Law.' PROVIDE MFG R.INSTALLATION SPECS. ❑I am exempt under Sec. ,B a P.C.for this reason Owner Date WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: 'v-�/ 1 El I hew,and wA maintain a Certificate of Conserv to sel4lrreure for Worl e's Compensation, BUlldln as pmvis Is for by Section 3100 0l the Labor Corte,for the pedormarhce of Me wwk for which this �� o 1 OD ast pu Is Issued. //L) ��ry y/ ^// I have and will maintain Workers Compensation Insurance,as required by Section 3]00 of IV• /r—` / ( ) Seismic the Labor Cade,for Me performance of the work for which MIs Permit Is issued.My Workers Compensation Insurance terrier and Polley number are: Total Carrier Policy No. PER A HORI N DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.CQ (This sedan need not be completed If the permit Is for one hundred dollars($100)or lase.) I certify that in the pedprmance of the work for which this permit is Issued,I shall not employ arty person N arty manner So as to become Subject to Me Workers Compensation Laws of Cell- All roof all be inspected prior to any roofing material being fol install q // Pit p t� e I d. If a roof Is installed without first obtaining an Date 14 r APpicamt jou Us 410-Dixi �t✓ ins action,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making this Cedlllcate of Exemption,you Should become A II Subject to the Workers'Compensation provlslons of the L¢Wr Code,you must forthwith comply PPC nderslandS and WIII comply with all non point with such proNslons or Mia penNt shall be deemed remked. so CriI certify that I how read this apullcatlon aM state Met the above Information Is conect.I agree to comply with all city and county ordinances and state laws relafirg to Wilding conslructbn,ane I r0o be class"C"or better. hereby authorize reposentat"s of this city to enter upon the abvre-mentioned property for In. sp wail purposes.(We)agree S sew,Indemnity entl keep h ny ways the Clty of st sladrC agrumstcon Ilebllen e,ludpmentscostsentl expenses witch may In arty way accrue against sold City In consequenceonhegraurgofIN rmLSIGPPLICANT 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE411I INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE • CITY OF CUPERTINO BUILDING PERMIT INVOICE OPERATOR: karenb Sec: Twp: Rng: Sub: Blk: Lot:35702038.00 INVOICE DATE..... . : 10/11/1999 REFERENCE ID # .. . : 99100052 SITE ADDRESS .... . : 10303 MIRA VISTA AV SUBDIVISION ..... . . CITY . . . ......... . : CUPERTINO IMPACT AREA ...... . OWNER .. . . . ....... : RANDY MACHUD ADDRESS . . . . . ..... : CITY/STATE/ZIP ...: CUPERTINO CA, 95014-2718 CONTRACTOR . . . . ... : LIC H COMPANY . . . . . . ....: ADDRESS . . . . . ..... : CITY/STATE/ZIP ... . , TELEPHONE . .. . .... : FEE DESCRIPTION CHR TOTAL FEE PAID-TO-DATE BALANCE DUE --------------- --- --------- ------------ ----------- BPERMFEE P 137.00 0.00 137.00 BSEISMICRE P O.BO 0.00 0.80 137.80 0.00 137.80 \. ID DESCRIPTION VOICE ID DESCRIPTION ........ ............................ ........ ............................ 305 FRAME 307 INSULATION 601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 603 ROOF BATTENS 604 ROOF IN-PROGRESS • • CITY OF CUPERTINO Item 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: karenb COPY # 1 Sec: Twp: Rug: Sub: Blk: Lot:357D2038.00 DATE ISSUED. . ..... : 10/11/1999 RECEIPT q.. . . .. ...: 10291 REFERENCE ID 4 ...: 99100052 SITE ADDRESS . . .... 10303 MIRA VISTA AV SUBDIVISION . . . ... . CITY ... . . . . . .. ... : CUPERTINO IMPACT AREA . . . .... OWNER ...... . . . . ..: RANDY MACHUD ADDRESS ... .. . . . . . : CITY/STATE/ZIP . ..: CUPERTINO CA, 95014-2718 RECEIVED FROM . . . .: JOB S CONTRACTOR ....... : LIC # COMPANY ......... . : ADDRESS .......... : CITY/STATE/ZIP . . . . , TELEPHONE .... . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL _____ __________ ---------- ---------- ---------- BPERMFEE VALUATION 8,000.00 137.00 0.00 137.00 0.00 10MICRE VALUATION 8,000.00 0.80 0.00 0.80 0.00 TOTAL PERMIT 137.80 0.00 137.80 0.00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ -----------'""'-- . CHECK 137.80 1244 `v TOTAL RECEIPT 137.80 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