99070043 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBS
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)7n-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
DAYS FROM LAST CALLED INSPECTION.'
BUILDING ADDRESS f� O
RESIDENTIAL COMMERCIAL OTHER
OMER•S HAZARDOUS FIRE AREA-
NAME `ilk bti b K/N"�/1 NVY) '"`( )"'I I VES.'❑ Irod esserMyderIs roquired.
stand Most a Cless A
ADDRESS � � F-s/Y Y I�I! l�A �� � ' NO ❑ Initial I.C.B.O..t
EXISTING ROOF COVERING
PON �0 g
� Og NUMBER OF EXISTING COVERINGS I
CONTRACTOR'S
r. / /I TO BE REMOVED TO BE RETAINED
NAME li(A
ADDRESS ,i1 1 LI &fj 'I 5 '- TYPE OF ROOF COVERING
CITY aZIP—
�Vbn V EXISTING
PHONE— BUILT-UP ROOF ❑
LICENSE ' 7vl�lV�
NUMBER r 1 { / ASPHALT SHINGLES 1:1
LICENSED CONTRACTORS DECLARATION
I hereby affirm Met I em licensed under prcrrff na of Chapter B(commencing with Sectfon WOOD SHAKES - -
7000)of Division 3 of the Business and Professions Code,,�andnd myyy llliicce/n/,see is IInn(full force and
offLice n �2 11L 1 V�✓�/Y
J WOOD SHINGLES ❑
License class
Us.Number -
Daro Convactor CAL[vLLt.(x Z OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
1 hereby aHMn that I am exempt from the Contractors License Law for the following reason.
(Set.7031.5,Business end Profession,Code: Any city or county which requires s permit to
construct,after,Improve,demolish,or repair any structure,prior to Its leweroe,also requires the BUILT-UP ROOF - Elapplfoant for such permit to lib a signed statement that he is licensed pursuant to Me provisions
of Me Contractors Ucenea Law(Chapter a(commencingp with Section 7000)of Division 3 of the
Business end Protocol Code)or that he is exempt Therefrom and the basis for the alleged ASPHALT SHINGLES ❑
exenptbn.Any Actuation of Sedbm 7031.5 by arty applicant for a permit subjects the applicant Ise tivlI P. Ity,of not more than five hundred dollars(S-50i
❑I,as owner of the property,or my employees with wages as their We compensation,will do WOOD SHAKES ❑
Me work,end Me structure Ie not Intended or cheroot for sale(Sac.70",Business aM Pmfes.
slons Code:The Cmtreetors Ucense Lew does not appy to an owner of property wia bul cts or WOOD SHINGLES Improves thereon,and who does such work himself or through his own employees,provided Chet E] x
such Improvements are not Intended or offered for sola.If,however,the building or Improvement
c add wMln me year ofcompletion,the ownerrbullder will have Me burden of prWrg that he da OTHER (SPECIFY)
not build a Improve for purpose of sale.).
❑I,as owner of the properly,em exclusi
vely contracting with Ilcenaad contractors to construct
the protect(Sao.7014,Business and Professions Code:Tne Contractors License Lew does not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who builds or Improves Thereon,end wio contracts for such projects
with a contractor(s)licensed pursuant to Me Contractors License Law.
❑I am exempt under Sec. ,B 6 P.C.for Mie rearl PROVIDE MFGR.INSTALLATION SPECS.
Omer - Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the folhwvirp declaration:
I hese and will maintain a Gerdilcato of Consent to aellaneure for Workers Compensellm. ^ ^�/�yl I ^ ODO Building
as provkfad for by Section 3700 of the Labor Cods,for the performance of the work for which this �/ / / 1 f—I u/
permit fo Issued. r�V I Seismic
1 have aM will maintain Worker's Compeneatfon Insurance,u required by Seddon 3700 d
M Labor Coda,for tiro performance of the wok for which this permit is Issued.My Workers -'MW/��,/�/
Campensa��tlm lL]�nsurc
ree carrier arcrd Pol'icy\nnum�r are: Total CT_O.�(L4L
cerrier � Yl� POIityNo.71.LL1� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.[
(This section need rot be comdeted If Me permit Is for one hundred dollars($lW)or lees.)
I tardy Chet In lite performance of the work for which this permit Ie Issued,I shall rotmro by
arty person In amy manner w as to be o ,object to Me Wo Mm'Compensation Laws of Cell All roofs shall be inspected prior to any roofing material being
fa"'ro- installed. If a roof is installed without first obtaining an
Date Applicant inspecfion,I agree to remove all new materials for inspection.
ctoe� Cafter
tMworkocirs�penaon ovbbof Me boCode,you Exemption,
lroMwnh become Applicant understands and will comply with all non point
with such providers or this permit shall be deemed revoked. Source regulations.
I cantly that I hese reed this application and state Chet the above Information is cormt.I agree
to comply with all city and county ordinances and elate laws relating to building construction,and All roof veri�b las or er.
hereby authorize representatives of Mie city to enter upon the above-mentioned property for In-
spectron purposes. I �i
(We)agree to says,IMerrnity and keep harmless the City of Cupertino against liabilities,
Judgments,costs and crudeness which may In any way accrue against said City In consequence A RE OF APPLICA DATE
of the gra tri of MIS permit.
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
OBUILDING PERMIT INVOICE OPERATOR: karenb
Sec: Twp: Rng: Sub: Blk: Lo[:35701066.00
INVOICE DATE......: 07/23/1999
REFERENCE ID # ...: 99070043
SITE ADDRESS .....: 22374 RAMONA Cr
SUBDIVISION .......
CITY ..... ........: CUPERTINO
IMPACT AREA ...... .
OWNER ... ......... : BOLEDA ALBERTO AND MARILYN R T
ADDRESS .......... : SAME .
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-2733
CONTRACTOR ....... : KAHN, RUSSELL LIC # 17999
COMPANY .......... : CROWN ROOFING INC
ADDRESS .......... : 214 CRISTICH LN
CITY/STATE/ZIP ... : CAMPBELL, CA 95008
TELEPHONE ........ : (408)369-7444
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPERMFEE P 217.00 0.00 217.00
BSEISMICRE P 1.60 0.00 1.60 -
218.60 0.00 218.60
VOICE ID ----------------------------
-_DESCRIPTION .-..---- 707
VOICE ID -..- DESCRIPTION
FRAME 30]
.. ---------- -.. INSULATION --------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF IN-PROGRESS 604 FINAL REROOF