99090088 �3. S-� 07 b 9ogOoee
PERMIT W
APPLICATION FOR clTv OF cuPERTINO NUMBER RAW
PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 EXPIRESPERMIT IS NOT
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING/,ADDR{EETSSIS /, ''j' bio
Ot F✓ /�IL / Xf"c..� Dif"• RESIDENTIAL _COMMERCIAL OTHER
OWNER'S1 I� y.�' _ - HAZARDOUS FIRE AREA ,
NAME S vs,' V e / y y YES ❑ Il yes—I understand Kai a Class A
mol assembly is requited.
NO ❑ trYtial I.C.B.O.R
ADDRESS �D�zy �i9'�' / hr�-� �/. EXISTING ROOF COVERING.
PHONE. NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
r TO BE REMOVED / TO BE RETAINED
NAME 4E f i✓U (�Z;, ,
ADDRESSTYPE OF ROOF COVERIN
clTv s ZIP 7� S. J �• l��/
EXISTING
PHorG�08� Z BUILT-UP ROOFX 40
NICENE4/� ❑ /S
NUMBER / C� ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing coon WOOD SHAKES El7000)of Dlvlelon 3 of the Business and Protesslons Code,and my license I r en
cited. gil
Literate Class G Uc.Number LZ- LIPS
❑
Dote 5'/C 9 9 Contrectar C/ /�`� OTHER( �r'1 ❑
O t from BUILDER DEC's LicenON
se
1 E
hereby031.affirm in that I am exempt from Co e: Any dry License Lew br the bile
(Sec.7031.5,Business entl Professions rep Codd: Any dry or county which raquiroe o
ad ascan EON
filar,Improve,tl file a signed
or repeat any structure,prior to he leers r the T UP R
of t
applicant for etch permit to lila a signed statement that g i t Section
purer p it
of the .a and
LIcense Lew(Chapter 9 Is ex(commencing t with therefrom
and 7000) o e ��
Bueinass entl Profeasbns Code)or that M Is exempt iherelram and the" e h ❑
exemption Any violation of Section 7031.5 by any applicant for a permit subl Ih
e dull penalty of not more than five hundred dollars(5500).): ^ rl
❑I,uowner of Ne property,or my employees with wages as Moir We carpensetbn,wllldo WOOD SHAKES //�\❑ ILII
the work,and the structure is net Intended or offered for sale(Sec.7044,Baroness,and Pmfes. D ❑
short Code:The Contractors Lienee Law does not apply to an owner of property who buiks or WOOD SHINGLE
improves thereon,and who does such work hlmseti or through hie own empbyees,provided that
ouch improvements are not Intended or offered for sale.If,however,the launching or Improvement ( SEP
'1 �ggg
Is holtl withln one year d completion,as owner-bulldar will have the burden of proving that Mfid OTHER SPECIFY JLf 1
not bditl or Improve for purpose of sale:). L./
❑I,as owner of the property,am exclueovoy,contracting with licensed contrenors to construct
the project(sac.lona,Business and Prof tesla s Code:The Contractors License Law does not PROVIDE I.C.B.O. PORT NO.
apply to an owner of property who busies or improves thereon,and who contracts for such projeds
with a contractor(s)Ilcensetl pumuem to site Contractors License Law. PROVIDE MFGR.I STA OT�'SPECS�Z ' (%
1 am exempt under Sec. ,B 8 P.C.for this reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following decoration:
' [-I I have entl wl II malnteln a Certificate of Consent to self-Insure for Worker's Compensation, Building
as,provided for by Secret 3700 of the Labor Coda,for the performance of the work for which this C S% yg g
pernYl Is blued. 1 O
1 have and will malnteln Worlaerb Compensation Insurance,as required by Sedan 3700 of Z5-p — Seismic
the Labor Code,for the performance of the work for which Ihb permit,is Issued.My Workers O
Compensation Insurance carrier and Polley number are: Total /
s�� z
Cerrler/_TLIT:/�/�A+'� UU L 7v-
00 PERMIT AUTHORIZATION DATE
CERTa KATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This secllon raed rat M completed b the permit is for one hundred dollen($100)or lees.) '
I cardly that In the performance of the work for which this permit Is Issued,I shall not employ
arry person In any manner so as to become subject to the Workers'Compensaton Laws of Call. All roofs shall be inspected prior to any roofing material being
funis. installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTE TO APPLICANT: IL after making this Coruscate of Exemption,you should become Applicant understands and will con
subject to the Wonders'Compensation provisions of tre Labor Code,you must forthwith wrap y pP ply with all non point
with such provisions or this permit shall be deemed revoked: source regulations.
I certity that I have read this application and state that the above Inbnnaft n le coned.I agree
to comply with all city antl county ordinances errs state laws reefing to buildng conetmctlon,entl All roof coverings�be �. Orbetter.
hereby authorize representatives of this city to enter upon IM above-msntbnetl property b(In-
spection purposes.
(We)agree to save,Indemnify and keep harmless The Gy d Cupertino agslnst labllWez,
ju monis,costs and expenses which may In any way accrue against said City In consequence
o1 tie granting of this permit. _SIGNATJAE 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
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: Rng: Sub: Blk: Lot:35607045.00
INVOICE DATE......: 09/14/1999
REFERENCE ID # ... : 99090088
SITE ADDRESS ..... : 10696 PAR THREE DR
SUBDIVISION ...... .
CITY . . . .......... : CUPERTINO
IMPACT AREA ...... .
OWNER ............ : DE FOY, SUE
ADDRESS ......... . :
CITY/STATE/ZIP . .. : CUPERTINO CA, CA 95014-4025
CONTRACTOR .. . . ...: LIC W
COMPANY .... . . . . . . :
ADDRESS ...... . . . . :
CITY/STATE/ZIP ...
TELEPHONE .. . . . . ..:
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
___ --- --------- ------------ -- --------
BPERMFEE P 147.00 0.00 147.00
BSEISMICRE P 0.90 0.00 0.90
--------- ------------ -----------
147.90 0.00 147.90
ID -- DESCRIPTION......... VOICE ID DESCRIPTION
FRAME 307 INSULATION
ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
CITY OF CDPERTINO '
1 of 1 BUILDING PERMIT RECEIPT OPERATOR: christya
COPY # 1
Sec: Twp: Rng: Sub: Blk: Wt:35607045.00
DATE ISSUED.......: 09/14/1999
RECEIPT N......... : 10066
REFERENCE ID # ...: 99090088
SITE ADDRESS ..... : 10696 PAR THREE DR
SUBDIVISION .......
CITY ... . .. .......: CUPERTINO
IMPACT AREA ......:
OWNER . . . .........: DE FOY, SUE
ADDRESS .......... :
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-4025
RECEIVED FROM . . . . : TIM
CONTRACTOR ....... : LIC p '
COMPANY ..... . .. . .:
ADDRESS .... . . . . ..:
CITY/STATE/ZIP . . . .
TELEPHONE ... . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
________ _____ __________ __________ __________ __________ __________
BPERMFEE VALUATION 9,000.00 147.00 0.00 147.00 0.00
BMICRE VALUATION 9,000.00 0.90 0.00 0.90 0.00
---------- __________
T PERMIT 147.90 0.00 147.90 0.00
M OF PAYMENT AMOUNT NUMBER
_________________ ____________ __
CHECK 147.90 4852
............
TOTAL RECEIPT 147.90
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