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99080092 Z�� 3221 N: 3 2 - 3o - b35 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBS ARGM INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (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 .( -y 1 / q3 Ma I- I LLN t � RESIDENTIAL COMMERCIAL OTHER OWNER s HAZARDOUS FIRE AREA M Y Ro>J ST,�R A o s K 1 YES ClIf yes-I Understand that a Class A NAME root assembly Is required. l� p NO Initial I.C.B.O.Y ADDRESS � 3 1"`DLI �G�p,(/ -1�01� EXISTING ROOF COVERING PHONE U— Z — I 0 NUMBER OF EXISTING COVERINGS ' CONTRACTORS ��yf � � ✓ NAME f� lJ �UU�"t N Cf TO BE REMOVED TO BE RETAINED ADDRESSLos gTDS TYPE OF ROOF COVERING croszlP IOC A � 4A-J '�LkC c C75 03 2 EXISTING PHONE BUILT-UP ROOF ❑ LICENSE _/ NUMBER J ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm Met I am Ilceneed under provisions of Chapter B(commencing with Secdon WOOD SHAKES 7000)of Division 3 of the Business and Professions Corte,and my license is in full force and enact. -12 WOOD SHINGLES Ucense Clens C3 I Ut:Wunb¢n -7- •7- / ` p ((/ L_ FOX- OTHER(SPECIFY) Date II UU Contracts{, /e OWNS ttheConROECL Llcome "l; PROPOSED hereby affirm that am exempt from the Contractor's Lkerae Lew for the to ng reason. I /� (Sec.-7031.5,Business and Profeselons Corte: Any city or county which requires a permit to 7 construct alter,Improve,demolish,or esti any structure,Is Ilcoo Its issuance,to me the BUILT-UP ROOF �� ❑ eppllcent for such permit to Ills a signed statement ilial he la Ilconsetl pursuant 10 the provldons \❑\ of the Contractors License Law(Chapter 0(commencing with Section 7000)of Division 3 of the Buslnem am Professions Coda)or that he Is exempt therefrom and the basis for me alleged ASPHALT SHIN exemption.Any violation of Secgon 70.31.5 by any applicant for a permit subjects the appekant to ! a civil penalty of not more than five hundred dollars(5500).): - 6 alb ❑I,as owner of the property,or my eotpeoyem with wages as their ado compensation,will do WOOD SHAK 6 ❑ Me woM,and the structure is not intended or offered for sale(Sec.7044,Business and Proes- 6l y T slons Coda:The Contractors License Law does not apply to an owner of property who bulica or WOOD SHIN 6 ` �n Improves thereon,and who does such work himself or through his own employees,provided that Q such improvements are not Intended or offered for sale.If,however,the bulking w Improvement _ is sold within one year of completion,the ownerbuikfer will have the burden of proving that he dirt OTHER(SP \\Zcv`�di? ret build or Improve for purpose of sale.). _ I]1,as owner of the property,am exduswely contracting with licensed contractors to construct the project(Sac.7044,Buslness and Proleseons Code:The Corra is Usama Law does not PROVIDE I.C.B.O.REPORT apply to an owner ol property who ounce or Improves thereon,and winter contracts for such projects with a contractor(s)licensed pursueat to the Contractors Lkoense Lew. PROVIDE I INSTALLATION SPECS. I am exempt under Sec. ,B 8 P.C.for this reason Owner Date APPLICATION DATE •' VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalry,of perjury one of the following declaration: i ❑ have arrtl will maintain a of the Ib d Consent to epmfiorum ce Workers for winch this II II I up 1mve and Sector,Mintain a Cmi Labor Code,amt the performeree of Workers CorinwhMNis Xpe besued. �IlZlggI`ItD�3. Seismic _ neva antl win malnteln Workers Cortyoraation Itaurance,ea required by Section 3700 0l I I ��e 1/7 r Code,for the performance of the work for which Nis permit le issued.My Welfare ,�.Q.ai/ omperaatkatlnaurartco co ter enol Fbllcy,number are 1/s 11 Total Carrier ( At PollcyNo./jI—If)bTU PERMIT AUTHORIZATI DATE CERTIFI A N FROM WORKERS' COMPENSATION INSURANCE N lion naetl rwr be completed it the permit Is b one hundred dollars(5100N)) (The when or lees.) I certlly Ilial in the performance of the work for whidt this permit Is Issued.I shall not empty any,person In any manner so as to became subject to the Workers'Compensatbn I.am of CM, All roots shall be inspected prior to any rooting material being foals. installed. If a roof is installed without first obtaining an Data Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you Mould become Applicant understands and will cpm sublad to the Workers'Compensation provisions of the Labor Code,you must forthwith coaly pP ply with all non point with such provLWons or this permit shell be deemed reval source regulations. I sadly that I have read this application and state that the above Informal n Is correct l a r to comply with all dry al county ordinances and state aws relating to bullailg conetrvil antl II r00 coverings class"C"or better. hereby authorl representatives of this dry to enter upon the above-mentbned props br In- 'emotion purposea. (We)agree to save,Indemnity and keep harmless the City of Cupertino against Ila dies, IL Judgments,costs and expenses which may In any way accrue against said City In wnsequ of the granting of this permlL GNATURE APPLIC) NT 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 OFFICE COPY INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE CITY OF CUPERTINO BUILDING PERMIT INVOICE OPERATOR: chri.tye Sec: Tp: R g: Sub: Blk: Lot:36230035.00 INVOICE DATE.... .. : 08/12/1999 REFERENCE ID # ...: 99080092 SITE ADDRESS .....: 7543 MOLTZEN DR SUBDIVISION ....... CITY ... . . . . ......: CUPERTINO IMPACT AREA ....... OWNER . . .......... : STYRANOVSKI MYRON TRUSTEE ADDRESS .......... : CITY/STATE/ZIP . .. : CUPERTINO CA, 95014-5048 CONTRACTOR . . . . . ..: PROCTOR, PAUL LIC # 19698 COMPANY .... . . . . .. : R E ROOFING ADDRESS .... . . . ...: 108 OAKLAND PL CITY/STATE/ZIP ...: LOS GAMS, CA 95032 TELEPHONE .. . . ....: (408)925-9995 FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE _______________ ___ _________ ____________ BPERMFEE P 207.00 0.00 207.00 BSEISMICRE P 1.50 0.00 1.50 _________ ____________ ---________ 208.50 0.00 208.50 V ID DESCRIPTION -------- VOICE ID DESCRIPTION . ............................ ...... .... ........ ............................ FRAME 307 INSULATION ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 603 ROOF BATTENS 604 ROOF IN-PROGRESS s CITY OF CUPERTINO I� 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: chrletya COPY 1 Sec: Twp: Rng: Sub: Blk: Lot:36230035.00 DATE ISSUED....... : 06/12/1999 RECEIPT q......... : 9800 REFERENCE ID N ... : 99080092 SITE ADDRESS . . . . . : 7543 MOLTZEN DR SUBDIVISION .. . . . . . CITY ........ . . . . . : CUPERTINO IMPACT AREA . . . . ... OWNER .... . . ......: STYRANOVSKI MYRON TRUSTEE ADDRESS . . ........: CITY/STATE/ZIP ...: CUPERTINO CA, 95014-5048 RECEIVED FROM .... : CAVES CONTRACTOR ....... : PROCTOR, PAUL LIC p 19698 COMPANY . ...:..... : R E ROOFING ADDRESS .......... : 108 OAKLAND PL CITY/STATE/ZIP ... : LOS GATOS, CA 95032 TELEPHONE ........ : (4081925-9995 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW HAL __________ _____________ ____ _ __________ BPERMPEE VALUATION 15,000.00 207.00 0.00 207.00 0.00 BSEISMICRE VALUATION 15,000.00 1.50 0.00 1.50 0.00 __________ __________ __________ __________ PERMIT : 208.50 0.00 208.50 0.00 is OF PAYMENT AMOUNT NUMBER ___________ ____________ __________________ CHECK 208.50 3007 ------------ TOTAL RECEIPT 208.50 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