99100023APPLICATION FOR
REROOF PERMIT
�J � 0�
ERS Im1! W \ . 1v Vert V Iv V' L�
ADDRESS LI
PHONE
NAME—A
ADDRESS
CITY I ZIP
PHONE–
LICENSE
NUMBER
O x-13
CITY OF CUPERTINO
INSPECTION DIVISION
(408) 777-3228'
I hereby efflrm Chet I am licensed under provislare of Chapter 8 (commencing with Section
]000) of Division 3 of the Bus] lks and Professions Code, and! my license is In full force and
effect
Ucanee CI Uc. Number
2K�5 12-9
Date Contractor
ER -BUILDER D RATION
I heretry, affirm that I em exempt from the Contractor's License Lew for the blbMng reason.
(Sec. 7031.5, Business and Professions Cade: Any city or county which requires a permit to
construct, alter, Improve, demolish, or repair any structure, prior to Its Issuance, also requires the
applicant for such permit to file a signed statement that he Is t �licensep ! pur�suanotl to the provisions
:ml
of Id
etll e r t cs r! ^ Is the ep laice�ntelo
r£ongensetlon, win do
Buaineas, and Probe.
property who Wlbe or
Iployees, provided that
Is sow wlthIrF& eeYat cengMtiorI!If f-0tlM WMAr 944Mbof proving that he did
not Wild or Improve for purpose of sale.).
e 'M lu ors to conetrud
the p neo t rof t Li a Law tloes not
app) n rc o p o t for suchprolruo
the ni or
1 am exempt under Sec. ,B 8 P. C. lar this reason
PERMIT JJJW '
NUMBER
,PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1K DAYS OF PERMIT ISSUANCE OR
1W DAYS FROM LAST CAI IED INSPECTION.
COMMERCIAL OTHER
YES ❑ If yes– I understand that a Class A
roof assembly is required.
NO ❑ Initial I.C.B.O. C
NUMBER OF EXISTING OVERINGS I
TO BE REMOVED TO BE RETAINED
TYPE OF ROOF COVERING
ExlsnNc 11
BUILT-UPROOIIJ ❑ .
ASPHALT SHINff OCT 6499
WOOD SHAKES
B
WOOD SHINGLES_
OTHER (SPECIFY) V_ ❑
PROPOSED
///00
BUILT-UP ROOF
/
ASPHALT SHINGLES
❑�/��
WOOD SHAKES
❑
WOOD SHINGLES
❑
OTHER (SPECIFY)
PROVIDE I.C.B.O. REPORT NO.
PROVIDE MFGR. INSTALLATION SPECS.
owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
hereby and under maintain
a of perjury one of the following self -insure
done for Wn: - ��-
❑ have end will maintain a of the La o of Consent to self -insure for Workers Compensation "Ichtlw, BUllding
as mit Is d kx by Section 3]00 of the Labor Code, for the performance nf the work for which this I O ` O
permit le Issued' 1 I 000Seismic
tAlhave and will the pelrf Workers Compensation Insurance, as requiredsu Section Workers 7
or Code, for the performance of the work for hich this permit Is Lssued. My Warkare
Compensation Insure carfare icy number �].���,��,� Total
canter Iicy Nol-1-`�21T")V`'�?" PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.Q ' ^
(This section need not be completed If the permit Is for one hundred Collars ($100) or lase.) tJ / „Q
I cartlfy that In the per ormemce of the work for win a permh is issu shell not a �O
any person In a men er w 88 to become subject t e orkera' Cone ealbn Laws i- All roofs Shall In acted prior to any roofing material being
f°"'ia' ,qq stalled. If a roof is installed without first obtaining an'
Date iJ Asp /spection, I agree to remove all new materials for inspection.
NOTICE TO APP ICANT: If, after malung this Certificate of Exemption, n� A I]cant understands and will coon I with all non point
subject to the Workers' Compensation provisions of the Labor Code, you must fort with compy PP p Y
with each provisions or this permit shell W doomed revoked. Source re Ons.
I certify that I have read this epplbation and state Net the above informal Is correct.I agree
to campy with all dry and county orcmamces and state Jews relating to balding corssiructlon, end All coveri gs to class C" better
hereby euthod¢e representatives of this dry to enter upon the above mentioned property ion In-
spection purposes.
f We) agree to save, inderm y and keep harmless the City of Cupertino against liabilllbe,
APAX
judgments, meta and expenses which may In any way accrue against lied City In consequence
of the arentlna of this oormh. NA E OF APPLICAN - DATE
PRE -INSPECTION:
IJ11luldele]�➢
INSP. DATE INSP. DATE
IN -PROGRESS:
INSP. DATE
TEAR OFF INSPECTION:
BATTENS: r
FINAL '
INSP. DATE
INSP. DATE
INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE4COPY
RECEIVED FROM ....: TIM
CONTRACTOR .......: LIC N
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP .... ,
TELEPHONE ........:
FEE ID UNIT
QUANTITY
CITY OF CUPERTINO
PD -TO -DT THIS REC
1 of
1 BUILDING
PERMIT RECEIPT
OPERATOR: christya
----------
0.00 227.00
__
0.00
BSEISMICRE VALUATION
COPY N 1
1.70
Sec: Tp; Rng:
Sub: BIk: Lot:35701058.00
T� PERMIT
DATE ISSUED.......:
10/06/1999
0.00
M D OF PAYMENT
RECEIPT W.........:
10252
REFERENCE ID #
...: 99100023
----------`------
6448
'
SITE ADDRESS .....:
22403 RAMONA Cr
226.70
SUBDIVISION .......
VOICE ID DESCRIPTION
CITY .............:
CUPERTINO
305 FRAME
IMPACT AREA .......
307
INSULATION
OWNER ............:
WONG SAMUEL M AND
ANITA S
ROOF PLYWOOD NAIL
ADDRESS ..........:
603 ROOF BATTENS
504
CITY/STATE/ZIP
...: CUPERTINO CA, CA
95014-2732
RECEIVED FROM ....: TIM
CONTRACTOR .......: LIC N
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP .... ,
TELEPHONE ........:
FEE ID UNIT
QUANTITY
AMOUNT
PD -TO -DT THIS REC
NEW HAL
---------- -------------
BPERMPEE VALUATION
----------
17,000.00
---------- -
227.00
----------
0.00 227.00
__
0.00
BSEISMICRE VALUATION
17,000.00
1.70
0.00 1.70
0.00
T� PERMIT
__________ __________
228.70
__________ __________
0.00 228.70
0.00
M D OF PAYMENT
AMOUNT
NUMBER
.-----------------------------
CHECK
228.70
----------`------
6448
------
TOTAL RECEIPT
226.70
VOICE ID DESCRIPTION
VOICE
ID DESCRIPTION
305 FRAME
307
INSULATION
601 ROOF TEAR OFF
602
ROOF PLYWOOD NAIL
603 ROOF BATTENS
504
ROOF IN -PROGRESS
0
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF COPERTINO
BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: Rng: Sub: Blk: Lot:35701058.00
INVOICE DATE......: 10/06/1999
REFERENCE ID # ...: 99100023
SITE ADDRESS .....:
22403 RAMONA CT
SUBDIVISION .......
BALANCE DUE
CITY .............:
CUPERTINO
IMPACT AREA .......
_
0.00
OWNER ............:
WONG SAMUEL M AND ANITA S
ADDRESS ..........:
CITY/STATE/ZIP ...:
CUPERTINO CA, CA 95014-2732
CONTRACTOR .......: LIC k
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP .... ,
TELEPHONE ........:
FEE DESCRIPTION CHK
TOTAL FEE
PAID -TO -DATE
BALANCE DUE
_-_
BPERMFEE P
227.00
_
0.00
-------____
227.00
BSEISMICRE P
1.70
0.00
1.70
----"""'
22-.70
------------
10.00
-----------
228.70
VOICE TO DESCRIPTION
VOICE ID
DESCRIPTION
. ............................
FRAME
-f,
........ ...................
307 INSULATION
1 ROOF TEAR OFF
602 ROOF
PLYWOOD NAIL
603 ROOF BATTENS
604 ROOF
IN -PROGRESS
C