99080016 0
3 �� yid as OdI
Es
MIT
APPLICATION FOR clry of cuPERTINo NU NUMB
INSPECTION DIVISIONPERMIT EXPIRATION
REROOF PERMIT (806)777-3228 . - PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1W DAYS OF PERMIT ISSUANCE OR
. - - 180 DAYS FROM VST CALLED INSPECTION.
BUILDING ADDRESS
/� I
; ' (LI— �` RESIDENTIAL COMMERCIAL OTHER
OWNER'S - - HAZARDOUS FIRE AREA
y YES ❑ If yes—I understand that a Cie ss A
NAME a `•f" W 1�Z _l efV/GC�� roof assembly is required.
-7 NO ❑ Initial I.C.B.O.N
ADDRESS/o_7 /_/W�rwik'i�Y AV �Os 405-4-ITECom- EXISTING ROOF COVERING
PHON voe) � O if>220 NUMBER OF EXISTING COVERINGS
CONTRACTOR'S (' �j ,. �" -
NAME AVi" J P4,�f.�S /2—trip- TO BE REMOVED TO BE RETAINED
TYPE F ROOF COVERING.
CITY&zta 6YSf �vl i�la ST. 'Sir G9. ' 2
/M EXISTING. .
PH04 '2 G- 0� BUILT-UP ROOF
uoervsE f p
NUMBER �c. ASPHALT SHINGLES
�(f p
LICENSED CONTRACTORS DECLARATION Iven
-
I hereby affirm Net I am licensed-unow provisions of Chapter a(commencing wllh Section WOOD SHAKES
7000)of DIVIlson 3 of the Business and Professions Cade,and my Ilcenes Is In full force and
effect' WOOD SHINGLES
License Clear uc.Number
Data OTHER (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from the Contractor's Dcarme Law,for the foawiing reason. _
(Sec.7031.5;Business and Professions Code: Any city or county which requires a permit to
construct,after,Improve,demolish,or repair any structure,prix to its Issuance,also requires the BUILT-UP ROOF E]applicant for such permit to file a signed statement that he Is licensed pursuant to the provisions
of the Contractor's License Law(Chapter B(cammwcinp wMh Section]000)of DMakn 3 of the
• Business and Prolesabne Code)or that he is exempt Ilteret.and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of rat more Nan five hunoreo dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole campensetbn,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for Sete(Sec.7044,Business and Proms-
akxte Code:The Contractor's Llcenes Law does not apply to an owner of property who builds or WOOD SHINGLES
Improves station,and who does such work himself or through his own employees,providetl that ❑
such Improvements are rat Intended or offered for Sale.It,howmmr,the Wilding or improvement
Is sok within one year of completion,the owner-builder will have me Wrden of proving met he did OTHER (SPECIFY) ❑
not Wild or Improve for purpose of Sala.).
❑I.as owmer of Ne property,am exclu Welly connectirq with licensed contmoors to construct
the project(sec.7044,Business and Professlons Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for Such projects
wIN a contractor(s)ucansed pursuant to the Contractors LJcanse law. PROVIDE MFGR.INSTALLATION SPECS.
❑I am exampt unow Sec. ,B 6 P.C.for this reason
Owner Date
WORKER'S CpAPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
�
I hereby athrm under penalty of perjury one of the following declaration:
❑I he"and will melntaln a Cornflower of Consent to sell-Insure for Worker's Compensation, Building
are provided for by Section 3700 of the Labor Code,for the parlorance of Ne work for which Nle OD
permit is Issued. $elsR1IC
E]I Nava and will maintain Worker's Compensation Insurance,as required by Section 3700 of
the labor Code,for the performance of the work for which thin permit Is issued,My Worker's' 1
Corpensatbn Insurance wnlar and Policy number are: Total `
Carder R?IIOnae uGk:e Jit Poll,Not4&JAA//7;76&-65 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[ -
(This section reed tat be completed If Me permit is for one Wtdred dollars($100)or Issa)
I certify that M the performance of the work for which thIs pen it is Issued,I shell no;employ
any person In any manner so as to became subject to the Wonerrs Compensation Laws of Can- All roofs shall be inspected prior to any roofing material being
fornla. 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: It,after making this CeMcate of Exemption,you should become ,applicant understands and will comply with all non point
Subject to the Wor'sarr;Compensation provielons of the Labor Code,you must forthwith comply
with such provielone or this permit Shall[be downed revoked. Source regulations.
I cerllfy Nat I have read this application and State that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to Wilding ronstmction,and All roo cov t class�or better.
hereby suthariza representetives of this city to enter upon the ebove�mwrwumd property for In-
epectkn Purposes. - 7-Z9 -�
(We)agree to save,Indemnify and keep harmless the City of Cupertino against liabilities,
Judgments.costs arc expenses which may In any way accrue against said City In consequsnce
of the granting of this permit SIGNA RE 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
f
CITY OF CUPERTINO
1 of 4 BUILDING PERMIT RECEIPT OPERATOR: karenb
COPY 4 1
Sec: Twp: Rug: Sub: Blk: Loe:36944004.00
DATE ISSUED...... . : 08/03/1999
RECEIPT M. . ....... : 9715
REFERENCE ID H ... : 99080016
SITE ADDRESS ..... : 20306 PACIFICA DR
SUBDIVISION ...... .
CITY .. . . . . ....... : CUPERTINO
IMPACT AREA ...... .
OWNER .. . . ........ : SIMPKINS FAMILY INVESTMENTS
ADDRESS . ......... : '
CITY/STATE/ZIP ... : SANTA CRUZ CA, CA 95062
RECEIVED FROM ... . : TIM
CONTRACTOR ...... . : LIC W
COMPANY ........ . . :
ADDRESS . ....... . . :
CITY/STATE/ZIP . . .
TELEPHONE ...... . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS RED 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
__________ __________
�L PERMIT 107.50 0.00 107.50 0.00
VOICE IO DESCRIPTION VOICE ID DESCRIPTION
Sana.... ............................ ........ ............................
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE 'INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: karCnb
•
Sec: Twp: Rug: Sub: Blk: Lot:36999004.00
INVOICE DATE. . . . . .: 08/03/1999
REFERENCE IO N 99080016
SITE ADDRESS . . . . .. 20306 PACIFICA OR
SUBDIVISION . . . .. ..
CITY . .... . . . . . . . .: CUPERTINO
IMPACT AREA . . . . . . .
OWNER .... . . . . . . . .. SIMPKINS FAMILY INVESTMENTS
ADDRESS .... . . . . . . .
CITY/STATE/ZIP . . .: SANTA CRUZ CA, CA 95062
CONTRACTOR . . . . . . .: LIC #
COMPANY ... . . . . . ...
ADDRESS .. . . . . . . . .:
CITY/STATE/ZIP . . .. ,
TELEPHONE .. . . . . . .:
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
1 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
i''