99110003(�? (�- 53 0003
OFFICECOPY
PERMIT R_ 6830
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WOW IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
IW DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL_ COMMERCIAL OTHER
OWNER'S ,x
HAZARDOUS FIRE AREA -
l`/
�'
YES ❑ If yes I that a Class A
-I/)
NAME O..f
s
roof essemdy is required.
assembly is
hl0 ❑ Initial I.C.B.O. &
�� -
EXISTING ROOF COVERING
ADDRESS
/
4`(p
NUMBER OF EXISTING COVERINGS
—
PHONE
CONTRACTO
//'�/ 2
NAME L!/�rL✓l� l�/l C_
TO BE REMOVED TO BE RETAINED
.-�
ADDRESS
crrvszlP 79a� ��u+c.� A�✓1 ut n 7�6
E O V
EXISTING
PHON So /9 _ Z
BUILT-UP ROOF %❑ '
LICENSE
NUMBER `� -
ASPHALT SHINGLES'
WOOD SHAKES
LICENSED under proAsh RS DECLARATION
herebyislon but em
nss untler 9ecand
Chapter 9 (comseisin
si lowebne of with
7000) of OMdon 3 of the Business and Proleselms Code, entl my license h In lull force entl
[Jg](\
enact.
WOOD SHINGLES D
D
License Cl e9 LIc. Number �
1%1��
1999
Date < < contractor _OTHER
(SPECIFY) ElOWNER-BUILDEROECLARAT
N
1 hereby Within that I am exempt ham the Contractors Oc mse Law for the fo,kxMng reason.
PROPOSED
By
(Sec. 7031.5, Business and Prolessgru Code: Any city or county which requires a permit to
construct, alter, Intprow,demolish, or repair any Structure, prior to he issuance, also requires the
BUILT-UP ROOF ❑
applicant for Much permit to file a aligned statement that he Is licensed pursuant to the provisions
of the Contractor's License Lew (Chapter 9 (commendwith Section 7000) ofDMsbn 3 of the
Business end
Buess Professions Code) or that he la exempt tlrerefr ar and the basis for the alleged
ASPHALT SHINGLES
exemption. Arty vloiatlon of Section 7031.5 by arty applicant for a permit sublectM the applicant to
a chill penalty of not more then five hundred dollars
.
❑ I, as Owner of the properly, or my employees with wages as their sole cnmpensetbn, will do
K
WOOD SHAKES ❑
the work, and the structure Is act Intended or offered for sale (Sec. 7044, Business and Profes-
sions Cade: The Contractors License Law does tat apply to an owner of property who tulips or
WOOD SHINGLES El
mvethereon, and who does such himye
work self or through his own emploes, prandod that
Such
such Improvements are not Intended or offered for Male. It, how amr, the building or Improvement
Is sold within one year of completion, the owner -builder will have the burcon of pro.•ing Met he Old
OTHER (SPECIFY) ❑
act build or Improve for purpose of sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct
,
the prolect (Sec. 70,1 Business end Professions Code: The Contractors Ucense Law does not
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of properly who builds or Improves thereon, and wire contracts for such projects
with a contractor(s) licensed pursuant to the Contractor's License Law.
PROVIDE MFGR. INSTALLATION SPECS. '
❑ 1 em exempt under Sec. ,B 8 P. C. for this answer
Omer Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑ 1 have and will maintain a CertHkate of Consent to salt -Insure for Worker's Compensation,
as provided for by Section 3700 of the Labor Cade, for the performance of the work for which this
-
/pC
Is
'/�
Building
perml 1s issued'
�` ! / (G /
D s T
ave and will maintain Workers Compensation Insurance as required by Section 3700 of
Seismic
t bor Code, for the performance of the werk for which this permit is issued. My Woders
CamPensa�ila%n
Total
"sur�aj�' rrler end Policy rxrm ere:
�d.�
Carrier Y JfwdPolicy No.L,�— 32 2-91 M7 2l
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCO
(This secticn need not be completed 11 the permit Is for one hundred dollam (5100) or less.)
I cerllfy root in Ne performance of nae work for which this permit is usued, I shall net employ
All roofs shall be inspected prior to any roofing material being
any person N a manner was to become inti t to e W kers co ensation Laws a Call-
f«rie.
installed. If a root is.installed without first obtaining an
Dale � Appdcent
inspection, I agree to remove all new materials for Inspection.
NOTICE TO APPLICANT: If, after making this Cedtiicete of Exemption, you Mbcutd become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply
Applicant understands and will comply with all non point
PP P Y P
with such prnrslo or this permit shall be deemed reaoked.
source regulations.
I sadly that I here read this application and elate that Ne mew, Information Is correct. I agree
to with all dry and county of ces and relating m bulldlrg cansinction, and
.All rODf COVerin s t c" or loaner.
hereby m this ter u,ewe
hereby epurpo a represenleWes of this dry to enter upon the abate-menibnetl property for In-.
-
ap We) purposes.
(We) agree to save, and keep harmless against liabilities,
oLCupaid
costs and expenses w mr e a
ensa9 which may In any way accrue against said City in consequence
Ci
SIGNATURE OF APPLICANT DATE
of me granting of this perms.
ofJudgments,the gran per
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
OFFICECOPY
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: chrietya
Sec: Twp: Rng: Sub: Blk: Lot:36633008.00
INVOICE DATE......: 11/01/1999
REFERENCE ID # ...: 99110003
SITE ADDRESS .....: 11691 REGNART CANYON DR
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: BLACK JAMES W AND BARBARA S TR
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4830
CONTRACTOR .......:
PETERSEN, JAMES LIC
# 14030
COMPANY ..........:
PETERSEN-DEAN INC
ADDRESS ..........:
7980 ENTERPRISE DR.
CITY/STATE/ZIP
...: NEWARK, CA 94560
TELEPHONE ........:
(510)494-9982
FEE DESCRIPTION CHK
TOTAL FEE PAID -TO -DATE
BALANCE DUE
--------------- ---
BPERMEEE P
---------------------
167.00 0.00
-----------
167.00
BSEISMICRE P
1.10 0.00
1.10
--------- ------------
168.10 0.00
-----------
168.10
isID DESCRIPTION
-------------------
FRAME
ROOF TEAR OFF
603 ROOF BATTENS
11
VOICE ID DESCRIPTION
307 INSULATION
602 ROOF PLYWOOD NAIL
604 ROOF IN -PROGRESS