99080019 in C3 io
PERMIT
APPLICATION FOR - clTv of cuPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 130 DAYS OF PERMIT ISSUANCE OR
130 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
4120 J'J1
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS
wA f YES ❑ M yes- understand that a Clens A
NAME l7M� /-l��fi- �G/e V l 6_S " assernbty is required.
NO ❑ Initial I.O.B.O.Y
ADDRES/Is�/�-?� yn//t�rnif �4U. �v5 �RTctS /i4. EXISTING ROOF COVERING
PHONE`YO ) -27 ?-0320 NUMBER OF EXISTING COVERINGS /
CONTRACTOR'S
Ni REMOVED / TO BE RETAINED
' AMEroy! SO_gSon 4 -
ADDRESS �
TYPE OF ROOF COVERING
CITY&ZPgY �rnl FF� . CA EXISTING
PHONE(7"U) a/ I—
O 3- - _ BUILT-UP ROOF .❑
LICENSE
NUMBER8" - ASPHALT SHINGLES
7LIC ❑ -
I4CONTRACTORSDECIARATION
I hereby affirm that I em licensed under provisions of Chapter a(commencing with Section WOOD SHAKES
7000)of Divalon 3 of the Busnem and Professions Code,and my license Is In full form and
efts
License Close ({�_ Uc.Number-
Y7a-/oS WOOD SHINGLES
late - �"�/"9 9 connector s Suns OTHER(SPECIFY) Z3I
OWNER-BUILDER DECLARATION PROPOSED
I hereby eillrm that I am exempt from the Contractor's License Lew for the allowing meson. 7
(Sec.7031.5,Business end.Professions Code: Any city or county which requires a permit to
conetmci,after,Improve,dar llah,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
Ii - El
for such permit to He a signed statement Ihe le Ilcenmtl pursuant to He provisions
of the Contractor's License Lew(Chapter a(commdnp enwith Section 7000)of Division 3 of the
. Business and Profemkxu Cede)or that he Is mempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Arty violation W Section 7031.5 by any eppliwn for a permit subjects the applicant to
e civil penalty of not more then five hundred!dollars(5500).):
❑I,Be owmf of the property,or my Pool with wages m Moir sees compensation,will do WOOD SHAKES ❑.
the work,and the structure is net Intended or offered for sale(Sec.7004,Business and Profes-
sions Cade:The Contractor's License Lew does not apply to an owner of property who bullets cr WOOD SHINGLES
Improves Hereon,arch who does such work himself or through his own employees,vrwlded that ❑
such Improvements era not Intended or offered for sale.If,however,the building or Improvement -
issoldwithlnoneyeerofcarr n;meowner-builder will have the burden of proving that he did OTHER (SPECIFY) ❑
net bulid or Improve for purpose of sale.).
❑1,as owner of the property,am exduelvaN contracting with laenaed contractors to construct
the project(Sec.7044,Business arra Professional Code:The Contractors Leen Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Wilds or lonc sHereon,and who conlrecls far such projects
with a contractors)licensed pursuant to the Convector's Ucense Law, PROVIDE MFGR.INSTALLATION SPECS.
[II am exempt under Sec. a&P.C.for We reason
Owner Date
WORKERS COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following doclareHon:
❑I have and will maintain a Genii of Consent to self-Insure for Worker's Compen atlon, -Labor Building
as pr 1doof for by Section 3700 of the Labor Code,for the performance of He work for which this C/�a O
ISRIIC
SB
per Cuetl. ,/7�
❑1 have and will maintain Workers Compensation Insurance,ars required by Section 37M of I'l
the Lobar Cade,for c performance of the work for which This permit N Issued.My Warker'e
ComPse
entbn Insurance carrier err Policy number are: Total s
CareerfGtf^^« J Pot y,No WA O 776d PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section seed ret W completed!If the permit Is for one hundred dollen($100)10)or tem.) �
I ceriily that in the peeormeree of the nark for which this permit 15 issued,I shell not employ
any person many manner m m to bemme aubjeat to urs Workers'Compensation Lwm call-
as All roofs shall be inspected prior to any roofing material being
Ionia. installed. If a roof is installed without first obtaining an
Data Applicant inspection,I agree to remove all new materials for inspection.
mgNOTICeet oE TO Wool
Pry�of Certificate LW�myou must
u otu M�owl�comoy cane Applicant understands and will comply with all non point
with such provisions or this permit Mall be deemed revoked. source regulations.
I call that I have read this application and state that the above Information is correct.I agree
to comply with all city and county ordinances and elate laws relating to building construction,entl All roof CO n .be Classr
" better.
hereby auihodze representatives of this city to enter upon the above-mentioned property for In.
specllon purposes.
(We)agree to save,Indemnity and keep harmless the City of Cupertino eoelnst IlebNllee,
judgments,costo and expenses which may In any lml ty way accrue egamid City n consequence
. 'ofthe Wanting atthis permit SIGNMTUREOFAPPLICANT 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
EDILDING PERMIT INVOICE OPERATOR: karenb
•
Sec: Twp: Rng: Sub: Blk: Lot:36999003.00
INVOICE DATE...... : OB/03/1999
REFERENCE ID fl ... : 990BOO19
SITE ADDRESS ..... : 20309 PACIFI CA DR
SUBDIVISION .. .... .
CITY .. . . . .... .... : CUPERTINO
IMPACT AREA ...... .
OWNER .. . . . . ...... : CHRISTENSEN ALEXANDER H AND IR
ADDRESS . . . . . ..... :
CITY/STATE/ZIP ... : SARATOGA CA, CA 95070-6237
CONTRACTOR . . ..... : LIC W
COMPANY . . . . ...... :
ADDRESS . . ........ :
CITY/STATE/ZIP ... . ,
TELEPHONE ........ :
i
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ ---__------
BPERMFEE P 107.00 0.00 107.00
BSEISMICRE P 0.50 0.00 0.50
--------- ------------ -----------
107.50 0.00 107.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
0O .. ............................ ........ ............................
5 FRAME 307 INSULATION
1 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 609 ROOF IN-PROGRESS
•
CITY OF CUPERTINO
�em 4 of 4 BUILDING PERMIT RECEIPT OPERATOR: karenb
COPY q 1
Ser Twp: Rng: Sub: Blk: Lot:36944003.00
DATE ISSUED...... . : 08/03/1999
RECEIPT b........ . : 9715
REFERENCE IO q ... : 99080019
SITE ADDRESS .... . : 20304 PACIFICA DR
SUBDIVISION ...... .
CITY . . . . . ........ : CUPERTINO
IMPACT AREA ..... . .
OWNER . . . . ....... . : CHRISTENSEN ALEXANDER H AND IR
ADDRESS . ........ . :
CITY/STATE/ZIP .. . : SARATOGA CA, CA 95070-6237
RECEIVED FROM .... : TIM
CONTRACTOR ....... : LIC b
COMPANY . . ........ :
ADDRESS . . ........ :
CITY/STATE/ZIP ... . ,
TELEPHONE ..... .. . :
FEE ID UNIT QUANTITY AMOUNT PO-TO-DT THIS REC NEW SAL
_______ __________ __________ __________ __________
BPERMFEE VALUATION 5,000.00 107.00 0.00 107.00 0.00
BSEISMICRE VALUATION 4,500.00 0.50 0.00 0.50 0.00
__________ __________ __________ __________
iL PERMIT 107.50 0.00 107.50 0.00
OD OF PAYMENT AMOUNT NUMBER
_____________ ____________ __________________
CHECK 430.00 1493
------------
TOTAL RECEIPT 430.00
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 .
•