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990900830 3S 6 -- 1_ a z PERMI APPLICATION FOR CITY of CUPERTINO NUMB INSPECTION DIVISION PERMITEXPIRATION REROOF PERMIT EXPIRES (408) 7773228 WITHIIN 180OF PERMIT ISSUANCA E OR 160 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS // - - RESIDENTIAL COMMERCIAL OTHER— OWNER'S - HAZARDOUS FIRE AREA n rj VES ❑If yes uWerstand theta Class - NAME "7 wiv�ww V�([V C///((U..((//M>•^y �� root esserndy is required. NO El. Initial I.C.B.O. N - EXISTING ROOF COVERING ADDRESSSc NUMBER OF EXISTING COVERINGS / - B �7-� —6L;F PHONE —5. / a- / CONTRACTOR' ~� CliTO BE REMOVED TO BE RETAINE NAME ' ADDRESS 5M. 4414L.u.t'� -�/\ Q CITY & ZIP 7 —}e-yc �� TYPE F ROOF VE '1 EXISTING BUILT-UP ROOF ASPHALT SHINGLES (U}I T3X999 �I 1� SEPLJ WOOD SHAKES 1 p PHONE �O 2–'l 0 L LICENSE NUMBER GsT 3 9. LICENSED CONTRACTORS DECLARATION I hereby affirm that I em Iicaroed under prwlslons of Chapter B (commencing with Section 7000) of Division 3 of the Buslrbea and Professions Code, aro Try license is In lull brce and . olfen. 457 WOOD SHINGLES By� Licensese a Dc. Number /3 (SPECIFY) ❑ Date ContractorOTHER PROPOSED O'NNER-BUILDER DECLAMTIO I hereby aHlirn that I am exempt from the Contractore license Law for the following reason. , (Sac. 7031.5. Business and Professions Code: Any city or county which requires a permit to conn after, Improve,demolish,« repatr any structure,oprlon to de lswance, also requires the ROOF El for such permit to file a signed statement that he Ls I1=ed pursuant to the on neons ,BUILT-UP of the in S 70D Mon 3 of the euampt n - x or the adepad r dw, slant ASPHALT SHINGLES �y7• � exempt a to a cOpe 1 $ I, as owner of M h_, es h e tion, win do - WOOD SHAKES ❑ Me work and at I o red for sale Sec. 7064 Bus nave and Profes. slons Code: tr a y party who bulks or WOOD there 'and r oyeae, provided that SHINGLES E)Improves such Improve 1 ding or Improvement Isithlna II II e f that he did / y proving bluff r 1e OTHER (SPECIFY) ❑ ❑I� r h re to co rust Ma prof a Tg. aw eoes not PROVIDE I.C.B.O. REPORT NO. apply to r t in , cts such projects, with e c e. C)I em exempt antler Sec. ,B 6 ,for tole reason PROVIDE MFGR. INSTALLATION SPECS. owner Date WORKER'S COMPENSATION DECIARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaration: ❑ 1 have and will maintain a Certificate of Consent to sedansura for Workers Cpmpeneatbn, f w provided kr by Section 3700 of the Labor Code, M the perbrmerne of Me work for winch this 1a �! `!/ /q /y i Building per jawed. "i and will maithe tainperformance Workers f the work for Insurance, as required by d. My Work7DDers 01 the bar Cade, for the pedormenca of the work kit which this permit k Issued. My Worsens ( / 1 1 (,l[ 7 Seismic 1 • C�� -Campeneatlo^n Ins��ca ranter end Policy number are. Total �R —% 9 -/00 PERMIT AUTHORIZATION DATE Cerneryi� i�_�y Policy No.2-�5 CERTIFICATE OF EXEMPTION FROM WORKERS' - �� COMPENSATION INSURANCE N.CL] (Tine settlor need rwt be completed If the permit Is f« one hundred dollere ($100) or teas.) I terlHy, liar In the performance of Me work for which this permit Is lewad, I shall not empty any person In any manner so as to become Subject to th Orkem' compensation Laws of Call- All roof^ shall be inspected prior to any roofing material being forNa. installed. If a roof is installed without first obtaining an Date Applicant N - inspection, I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If. after making this Carfilocadli of Exemption, you should became subject to the Workers' Compensation provlslons of the Labor Code, you must krihwlth comply Applicant understands and will comply with all non point PP P Y P with such provisions or this permit &JI deemed revoked. Source regulations. I minty that I have read thla appllcaticn end elate Mat the above Inlormetkn Is correct. I agree to comply with all city antl county ordinances and state laws relating to bulldIng mnstructlun,and All r7fri g obs cies "C"Or better.. hereby authorize representatives of Nis city to enter upon the above-mentioned property for In- ape Weros. (We) ) agree to save, Indemnify and keep harmless Me Clty of Cupertino against IIebIlNlee, ludgmenta, mate and expenses which may In any way accrue against mid CIry In consequence SIGNATURE O APPLICANT DTE ollhe-rending of tnk 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 • BUILDING PERMIT INVOICE OPERATOR: kerenb Sec: Tp: RnE: Sub: Elk: Lot:3S617023.00 INVOICE DATE......: 09/13/1999 REFERENCE ID N ...: 99090083 SITE ADDRESS .....: 11160 SANTA TERESA DR SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ......: OWNER ............: SPRINGER JO ANNE C ADDRESS ..........: CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4767 CONTRACTOR .......: LIC # COMPANY ..........: ADDRESS ..........: CITY/STATE/ZIP .... , TELEPHONE ........: FEE DESCRIPTION CHK --------------- BPERMFEE P BSEISMICRE P V ID ___.-.-.DESCRIPTION 5 FRAME 601 ROOF TEAR OFF 603 ROOF BATTENS 0 TOTAL FEE PAID -TO -DATE BALANCE DUE _________ 177.00 ____________ 0.00 ___________ 177.00 1.20 0.00 1.20 178.20 0.00 178.20 VOICE ID DESCRIPTION 307 INSULATION 602 ROOF PLYWOOD NAIL 604 ROOF IN -PROGRESS CITY OF CUPERTINO 1 0£ 1 BUILDING PERMIT RECEIPT OPERATOR: karenb COPY # : 1 Sec: Twp: Rng: Sub: Blk: Lot:35617023.00 DATE ISSUED.......: 09/13/1999 RECEIPT #.........: 10059 REFERENCE ID # ...: 99090083 SITE ADDRESS .....: 11160 SANTA TERESA DR SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OWNER ............: SPRINGER JO ANNE C ADDRESS ..........: CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4767 RECEIVED FROM ....: TIM CONTRACTOR .. .. .�: LIC # COMPANY ..........: ADDRESS ..........: CITY/STATE/ZIP .... TELEPHONE ........: FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS REC NEW HAL BPERMFEE VALUATION 12,000.00 177.00 0.00 177.00 0.00 BMICRE VALUATION 12,000.00 1.20 0.00 1.20 0.00 1. PERMIT 178.20 0.00 178.20 0.00 METHOD OF PAYMENT AMOUNT NUMBER _________________ ------------- CHEC% 178.20 ------------------ 10243 ------------ TOTAL RECEIPT 178.20 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- 305 FRAME """" 307 ""sea-------=------------. INSULATION 601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 603 ROOF BATTENS 604 ROOF IN -PROGRESS