99100126 3 3 DDI0�b
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777-3228 PERMIT EXPIRES IF YORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
® 1B0 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ,,qq
O /y� RESIDENTIAL L� COMMERCIAL OTHER.
OWNER'S //�� [�/ HAZARDOUS FIRE AREA
NAME_,l YES Ryes—(Understand flans ClassA
roof esserihily is required.
/ NO ❑ Initial I.C.B.O.11
ADDRESS /> ✓t't.� EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRAC/TO,R'/S�+ 'x� J� TO BE REMOVED TO BE RETAINED
NAME 1�1/FST S T t: (hQ RZ �T�d✓C.
ADDRESS •f�.L � qsj 3 TYPE OF ROOF COV ING
clTv a ZIP / n 4 EXISTING
6
PHONE Zy- Z oo BUILT-UP ROOF
LICENSE ` X/ v
NUMBER 39Y ASPHALT SHINGLES ❑ 01 '`
LICENSED CONTRACTORS DECLARATION 7�
I hereby affirm that I em licensed under provisions of Chapter 9(commenting with Sector WOOD SHAKES
]000)of DivLWon 3 of the Business and Professions Code,and my license Is in fult force and
iam.
LC 3 q /S7 > s WOOD SHINGLES /A
Date 10%3/
License Claes Uc.NmMer O J � RD cx--L1
l;Ylc' Contractor 'JESStroil &LUC, OTHER(SPECIFY 'UI ❑
OWNER-BUILDER DECLARATION PROPOSED f OCT 5 2 1999
1 hereby affirm that I em exempt from the Contractors Ucerse Law the following reason.
(Sec.7031.5,Buslress and Professions Cade: Any city or county which requires a permit to I
cwst=t,eller,Improve,demolish,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF ❑
applicant for Such permit to file a signed statement that he Is Ikensed pursuant to me provlslons By
of me Contractors Ucenae Lew(Chapter 9(commenclng with Section]000)of Dlvislon 3 of the
Business and Professions Code)or that he Is exempt tRerefrom and the deals for the alleged ASPHALT SHINGLES
exemption.Any vklerco of Section 7031.5 by any applicant for a peenll subjects me applicant to
e civil penally,of hot more than INS hundred dollars($500).):
❑I,as owner of the property.or nor employees with wages as their sole compensation,will do WOOD SHAKES ❑
me work•and me structure is not intended or offered for sale(Sec.7044,Business and Profes-
sions Code:The Contractor's Ucense Lew does not apply to an owner of property who it or WOOD SHINGLES
Improves thereon,and who does such work Monsen or through his own employees,provided that ❑ 1
such Improvamerts are not Intended or offered for sale.It,howwem,to building or Improvement ( 1
is sold within one year of completion,the owner-builder will have the Wrden of proving that he did OTHER(SPECIFY)
not build or Improve for purpose of sale.).
1,as owner of me property,am exduslvely contracting with licensed contractors to coni
the project Sec.7044,Business end Prolesslons Code:The Contractors Ukenso Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,antl who contracts for such projects
with a codhaciom(s)licensed pursuant to me Contractor's Uconse Lew.
❑I em exempt under sec. ,B d P.C.for this reason PROVIDE Vill INSTALLATION SPECS.
owner Date
WORKER'S COMPENSATION OECL/3iATION APPLICATION DATE VALUATION PERMIT FEE
I hereby slight under penalty of perjury one of me following declarator: /n�^ _
❑I neve end will mammon a Certificate of Consent to sen-Insure lar workers Compensation, Bulldin o%7 4D
as provided for by Seclldn 3]00 of the Labor Code,for me perbrmerwe of me work for which mW Building
o%7
is issued. / 9
❑I have one will maintain nonan e Compensation wisaton lrreure this p required is issu Section wori e's ( / Seismic
theCo Labor Code,for Via performernoe of me work br which this permit ui issued.My Workers
Corryensal Ineu` _rkr and Policy number are
Total
Carrier /� T(L Policy No.r-/LL PERMIT AUTHORIZATION DATE
CERTIFICATE EN EXEMPTION FROM WORKER' O(^
COMPENSATION the permit
INSURANCE (jG ,.NOCOjTJj
(Tills section need not be completed If me permit is for one hundred I
I certify that in the performance of me work lion which MIs permit Is' employ
any parson In any Turner so as to becom eugect to me Workers' pe tl of can- All roofs shall be inspected prior to any roofing material being
fools. 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 Certificate of Exemption•you should become Applicant understands and will comply with all non int
subject to the Workers'Compensation prwisions of the Labor Code,you must forthwith comply pP P Y point
with such provisions or this permit shall be or erned m coked, - source regulations.
I certlty that I have read this apphcetion and state mel the above Information Is correct.I agree
to comply with all city end county ordinances and state laws relating to building constrvctlon,end All roof cov sto be class re er.
hereby authorize representatives of thls clly to enter upon me abo nngntloned property for In.
opectlon purposes. C
(We)egroo to save,Indemnify and keep harmless the City of Cupertino a Incl IIeblluies, 25
judgments,costs arid expenses which may In any way accrue against said CityIn consequerwe SIGNATURE OF APPLICA DATE-
0-me granting of this 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE'COPY
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: karenb
f
Sec: Twp: Rng: Sub: Elk: Lot:36633005.00
INVOICE DATE.. . . . . : 10/25/1999
REFERENCE ID 9 .. . : 99100126 ,
SITE ADDRESS ..... : 11670 REGNART CANYON DR
SUBDIVISION ...... .
CITY .. . . . ....... . : CUPERTINO
IMPACT AREA ...... .
OWNER . . . . .. ...... : WEBBER LEE BRADLEY&ANNA DE BOE
ADDRESS . . . ....... :
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-4830
CONTRACTOR ....... : FOWLER, PAUL LIC N 21417
COMPANY . . . . ..... . : WESTSHORE ROOFING COMPANY
ADDRESS . . . ....... : 5869 WINFIELD BLV
CITY/STATE/ZIP ... : SAN JOSE, CA 95123
TELEPHONE . . .. .... : (40B)629-2100
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DDE
--------------- --- --------- ------------ -----------
BPERMFEE P 207.00 0.00 207.00
BSEISMICRE P 1.50 0.00 1.50
--------- ------------ ---------"_ i
208.50 0.00 208.50 - �!
0 ID DESCRIPTION VOICE ID DESCRIPTION i /e
__ _________________a_____..__. ----- -- ........----------- ........ tf
S FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
1