99110164r
)• -A
golimp
APPLICATION FOR CITY O1ag7i;�
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
- WITHIN 160 OAVS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
%�/�
(/J G 9 Nv r r `� wc/ �
�O I
RESIDENTIAL COMMERCIAL OTHER
_Alp�
(51fl s
HAZARDOUS FIRE AREA
YES ❑ tl yes _ I understandNet a Class A
NAME
roof assemdy Is required.
NO ❑ ktitfaf I.C.B.O. I
• �/
9 iz �I r
EXISTING ROOF COVERING
ADDRESS Z r i•t^ +✓ O'
G7
N Z' I
NUMBER OF EXISTING COVERINGS
PHONE / L
TO BE REMOVED TO BE RETAINED
CONTRAC ORON y S L (Y/• 6 f1
NAME Y—
ADDRESSP O QD / /r r1 c r
TYPE OF ROOF C
croszlPQ� C T ! �
EXISTING Z27NMI I
BUILT-UP ROOF ❑�// t ..f
PHONE /(� 2 I
LICENSE
NUMBER > C 3 a L
J
ASPHALT SHINGLES ❑ � 5���///
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em Ilcmwd under provisions of Chapter 9 (commencing witti Section
WOOD SHAKES
]000) of Division 3 of the Rushers and Professions Code, arxf my license is In lull force and
offset.
1_-
( � � �
WOOD SHINGLES ❑
Lkenee'C/4leyv � Lie. Number
r• Z `f �i p to G b
OTHER (SPECIFY) ❑
Data Common-, c. L-
OWNER -BUILDER DECLARATION
r I hereby affirm that I am exempt from Me Contractor's Ucense Law for the blowing reason.
PROPOSED
(Sec. 7031.5, Business and Professions Cada. Any city or county which requires a permit to
construct, eller, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the
BUILT-UP ROOF El
for such permit to file a signed statement that he is licensed pursuant to the provisions
no
of Me Contractor's License Law (Chapter 9 (commencing with Section 7000) of Dlvlslon 3 of the
Buelnese end PrIodr oWeel alleged
Any ciyt�p',k��ay�y�eplkani toNOV
o n g hu `'�l-�ls
ASPHALT SHINLESBom�t�n.
2 �4
SHAKErs
ryyam"In will do
WOOD
of IntanddQo04 Buslnese and Proles-
emsCode: The Contractors UINJ,ewd¢8y,pp(a t' f whabuilds c
Improves Marson, tl wali(p, hlgrseMOr provided that
such Improvements e t In oro er IQreal Improvement
WOOD SHING E3 Y ❑
Ie soio within one yea cam he r�bul III 'rg that he did
OTHER (SPECIFY)
- not bulio or Improve
i mWect
the Project (sa
❑ I, as owner of the pro rPr,aOuilt
appy tom n oJwitawntrea I
'PROVIDE I.C.B.O. REPORTNO.
se
❑ I em axe u reason
PROVIDE MFGR. INSTALLATION SPECS.
Owner Date
APPLICATION DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm untie, Penalty of Njury me of Me lallovnng doaeretlon:
-
❑ I he" and will maintain a Certificate of Cmsent to self -Insure for Workers Compensation,
C
Building
as provided b by Section 3700 of the Lebo de
Co, for Me perlormmers of Me work for which this
permit is Issued
/
1 �.
Seismic
❑ I have and will maintain Workers Cm hensatbn Insurance, as required by Seclbn 3700 of
the Labor Code, for Me Performance of the work for which this permit Is issued. My Workers
farm
Conpeneatbn lyneuryyeLInc�e(
`rra�m mbar are:
/ z/ L 4 O ' �'�
J_
_I
PERMIT AUTHORIZATION
DATE
Carrier V Pi No.
CERTIFICATE OF EXEMPTION FROM WORKERS
12 /j7
INSURANCE N.CL]
COMPENSATIONifIIIPermit
(This eectim need rql be completed it Permit Ie b, one hundred tldlers (Step) or lees.)
I certify that In the performance of deal week for which Otis permit is Issued. I shell rwt employ
All roofs shall be inspected prior to any roofing material being
any person In any manner so as to becoarr ea to Me Workers. comperforce Laws of Call-
fornla.
! 1 " CI L
installed. If a roof Is Installed without first obtaining an
Date Z 4 S Applleam GG�=-
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If, after making MIs Certificate of Exemption, you shmio bemme
sublect to the Workers' Compenmdon provisions of Me Labor Cade, you most forthwith comply
Applicant understands and will comply point
APP ply with all non Int
with such prmalons o this permit shell be deemed avoked.
source regulations.
I certify Met I have react this appllcation and state that the above Information Is correct. I agree
to comply with all city and county ordinances and state laws relating to building constructor, and
All r f coverings to be class "C" or better. "
hspembyn �z mepresentetivee of this city to enter umn Ma above-mentioned property b, in-,
action
1 `�' rr ^���
(We) agree to save, Indemnity and keep harmless the City of Cupertirw against liabilities.
ill...g
Judgments, casts and expenses which may in any way accrue against mid Clry In consequence
of Me granting of this Pommh.
SIGNATURE 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 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: nancyc
Sec: Twp: Rug: Sub: Elk: Lot:36611161.00
J
INVOICE DATE......: 11/24/1999
REFERENCE ID b ...: 99110164
SITE ADDRESS .....: 7629 NORMANDY WY
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: INCE CLARK S AND JACQUELINE E
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, 95014-5252
! ID DESCRIPTION
305 FRAME
601 ROOF TEAR OFF
G03 ROOF BATTENS
is
LIC N
PAID -TO -DATE BALANCE DUE
0.00
CONTRACTOR .......:
167.00
0.00
COMPANY ..........:
0.00
86.00
ADDRESS ..........:
_-__-254 10
CITY/STATE/ZIP
....
TELEPHONE ........:
FEE DESCRIPTION CHK
TOTAL FEE
---------------
BPERMFEE
---
P
---------
167.00
BSEISMICRE
P
1.10
BUSLIC
P
86.00
254.10
! ID DESCRIPTION
305 FRAME
601 ROOF TEAR OFF
G03 ROOF BATTENS
is
LIC N
PAID -TO -DATE BALANCE DUE
0.00
167.00
0.00
1.10
0.00
86.00
_-_-__----oo
0.
_-__-254 10
VOICE ID DESCRIPTION
307 INSULATION
602 ROOF PLYWOOD NAIL
604 ROOF IN -PROGRESS