99090196 qq q69PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNERS HAZARDOUS FIRE AREA
NAME iQ�•S /l�iQ/L�/4".�+'�P YES ❑ moof Ifyorassembly is required. gess A
NO ❑ Iridal LC.B.O.Y
ADDRESS / �.¢ EXISTING ROOF COVERING
PHONE e r / l_J 6 � �J CD NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME TO BE REMOVED TO BE RETAINED
ADDRESS TYPE OF R00fibtIVERING
CfTY&ZIP EXISTING
Ikf
PHONE BUILT-UP ROOF /Io
LICENSE —ziiiiii�
NUMBER '/
dq
LICENSED CONTRACTORS DECLARATION ASPHALT SHINGLES
I hereby affirm that I am licensed under provisions of Chapter B(commencing who Section WOOD SHAKES
7000)of Dlvinon 3 of the Business and Professions Cade,and my license Is In full force and
ellen.
WOOD SHINGLES ❑
License Claes Uc.Number
' O ❑
Date Contractor OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED ZJ_
hereby affirm that I am exempt from the Contractors License Lew for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to hI
canslruct,after,Impro demolish,or repair any structure,prior to its Issuance,elsorequires the BUILTUP ROQI� ❑ U
appscant for such permit to fife a signed statement that he Is licensed pursuant to the provisions
II
of the Contractors license Law(Chapter 9(cammencing with Section 7000)of Oration 3 of the n r1 g �gg
Business and Professims Coce)or that he m exempt Iherefmm and the basis for the waged ASPHALT SHIN�LES EP 2
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to If
e chrll penalty of not more then live hundred dollars WOOD SHAK S
❑I,es owner of the property,or my empioyaes with wages as their sole compensatlon,will do
the work,and the structure Is not intended or offered for sale(Sec.7044,Business and Proles. BV
slons Cade:The Contractors License Law does not appy to an owner of property who bunds or WOOD SHING ES
Improves thereon,and wtc does such w�orl,himself or through his own employees,provided that "
such Improvements are not Intended or offered for sale.It,howarer,the building or improvement
is Sold witlJn one year of completion,the owner-budder will hese the burden of proWrg that he did OTHER (SPECIFY) ❑
actbuildor Improve for purpose of s
sale.).
em,es ownor of the property,am exnusi"fy connecting with licensed coniraclas to consaroo
the project(Sec.704,Business and Professions Code:The Contractors Lioenm Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,erd who contracts for sari projects
witha omtractor(s)licensed pusuant to me Contractor's Llcense Lew. -` PROVIDE MFGR. INSTALLATION SPECS.
i am exempt under Sec. ,B 9 P.C.for this reason
Da KER'S COMPENSAECTION
APPLICATION DATE VALUATION PERMIT FEE
LyAA
1 hereby affirm under pe lowing declaration:
❑I have and will maintain a Certificate of Consent to seft-Ineum for workers Compensation, .Building
as provided for by Section 3700 of the Lobar Code,for the perbrmarce of the work for which his '
permit Is Issued. -
❑I have are will maintain Worker's Compensation Insurance,as required by Section 3700 of IJ 0 ep Seismic
the Latour Code,for the performance of me work for which this permit Is Issood.My Workers
Compensation Insurance carder and Policy number are: Total
Carrier Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NCC
(This vection need not be completed if the permit Is for one hundred donor,(51 00)or leas.)
I certify that In he performance of the work for which thla permit Is Issued.I shell not employ
any Person In any manner eo as to became subject to the Workers'Compensation Laws of Cali- All roofs shall bei spected prior to any roofing material being
forms. - installed. If a roof is installed without first obtaining an
Date 3 'D' <g,9 Applicant inspection,I agree to remove all new materials for inspection.
NOTICE a APPLICANT:Coo If,after malting
king onsftheLr Code.you m�fah h mthly Applicant understands and will comply.with all non point
subject to iia Workers'Compensation rang the Certificate the Leber Cafe,
with such provisions or this pormlt shall be deemed revoked, source regulations.
I cerlify that 1 have react this appllcatlon and state that the above information IS c mect.I agree
to comply with all pry and county ardnarcea oral stale laws relating to building construction,and All roof coverings to be class"C'�or better.
hereby authorize representatives of his city to enter upon Ite ebove-manidned property fort
specbon purposes.o
(We)spree to save,Indemnify end keep harmless he City of Coal IWbNure,
3 G /
Judgments,costs and expenses which may in any way accrue against sad City n consequence SIGNATU OF APPLICANT DAT
19
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: '
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 '
CITY OF CUPERTINO
1 of 1 BUILDING PERMIT RECEIPT OPERATOR: yvonnek
COPY # 1
Sec: Twp: Rng: Sub: Blk: LOC:36230045.00
DATE ISSUED. . . . . . . : 09/30/1999
RECEIPT q. . . . . . . . . : 10214
REFERENCE ID 4 . . . : 99090196 '
SITE ADDRESS . . . . . : 1194 RUPPELL PL
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACP AREA . . . . . . .
OWNER .. . . . . . . . . . .. HERNANDEZ CHRIS
ADDRESS . . . . . . . ... :
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-5049
RECEIVED FROM .... : TIM
CONTRACTOR . ...... : LIC q
COMPANY . . . ....... :
ADDRESS . ...... .. . :
CITY/STATE/ZIP . . . .
TELEPHONE .... . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW DAL
_____ ---------- ---------- ---------- --------
BPERMFEE VALUATION 10,000.00 157.00 0.00 157.00 0.00
BSEISMICRE VALUATION 10,000.00 1.00 0.00 1.00 0.00
---------- ---------- ---------- ----------
PERMIT : 158.00 0.00 158.00 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 158.00 0700
TOTAL RECEIPT . 158.00
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
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: yvonnek
Sec: Twp: Rug: Sub: Slk: LOC:36230045.00
INVOICE DATE. . . . . . : 09/30/1999
REFERENCE ID # . . . : 99090196
SITE ADDRESS . . . . .: 1194 RUPPELL PL
SUBDIVISION . . . . . . .
CITY .. . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . .. .
OWNER . . . . . . ...... : HERNANDEZ CHRIS
ADDRESS . . . . ...... :
CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-5049
CONTRACTOR . . . . . . . : LIC 4
COMPANY . ... . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
NOTE: THE FEES LISTED ARE ONLY THOSE DUE BEFORE PERMIT PRINTING
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ ------__---
BPERMFEE P 157.00 0.00 157.00
BSEISMICRE P 1.00 0.00 1.00
--------- ------------ -----------
158.00 0.00 158.00
ID DESCRIPTION VOICE ID DESCRIPTION
........ ............................ ........ ............................
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 6D2 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
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