99110029 l O �Z
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS I�C,fco U^� Z �vn1
ll�
RESIDENTIAL COMMERCIAL OTHER
OWNER'S . HAZARDOUS FIRE AR
YES EA
NAME �L'yl-�'Q{SOS - ❑ Ifyas—Iunderstantlttata CLMA
=1 assembly is regtdred.
NO ❑ Initial I.C.B.O.Y
ADDREss-wyaa SC.2r�<< 3��c9. EXISTING ROOF COVERING
PHONE qaIcL7� ^ p1.^1 V-8L'I NUMBER OF EXISTING COVERINGS I Shake, �'�IL
CONTRACTOR'S
NAME 1`O��•FAQ. I� y(OL�`f. Q,a TO BE REMOVED TO BE RETAINED
f\
ADDRESS TYPE OF ROOF COVERING
CITYBZIP 1 Z Irc3l� SI-41
PHONE L 1——1 W 6. S S /
LICENSE 1Li SG I ❑ �/
NUMBER —1 E ///
LICENSED CONTRACTORS DECLARATION A
hereby iaffirmnion that r usine eE under prvvislane of Chapter a(commencing with SSU /
]000)of Dlvlskxt 3 0l tea Btmineea and Prolesskxts Cade,and my license Is In full lone ertd
affect.
License Class, C/-
3q Lk.Number J L
Dale II—JC—''�1Q Cant raUor —
ED
OVMER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from Me Contractor's License Law for Me fallowing reason.
(Sec.7031.5,Business end PrUeesfomm Code: Any city or caunry which faculties a pertNl to
construct,a1w,Intel demolish,or repair any structure,prior to its lssuante,alsorequnut Ute BUILT-UP F
applicant for Such parNt to file a sigreci Satement that he Is Ikereed pursuenl to Me provisions
of Me Contractors License Iaw(Chapter B(commencing with Samon]000)of DNMon 3 of the n
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT NGLES ❑
exemption.Any,violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e chit penalty of not more than live hundred dollen u1 Va(CS
❑l,as owner of the property,or my employees with wages as their we campenswon,will do WOODS KE J Ou _ 5 1 19 1
Me work,aural the strucNre Is not Intended or offered for We(Sec.7061,Business and Pat".
sfons Code:The Contac ore Ucerwe Law does not apply to an owner of property who builds or .WOOD S INGLES
improves thereon,antlwho does such work himself or through his own employees,provided that yy ❑
Such Improvements are not intended or offered for sale.It,however,the building or improvement
Is sold within one year U completion,the owrter-0ulltler will have the burden of proving that he tlfo OTHER (SPECT
not build or Improve for purpose of sale.).
I,as owner of the property,am exduslvety contracting with licensed contrectore to construct
the project(sec.road,Business end Professions Cade:The Contrectore License Lew does not PROVIDE I.C.B.O.REPORT NO.
appy to at omar of property who ballast or improves thereon,and who contracts for such projects
with a contractors)Ilcensed pursuant to Me Contractor's License Lew. .PROVIDE MFGR. INSTALLATION SPECS.
F-1I am exempt under Sec. ,B&P.C.for thls reason
owner - Date
WORKER'S COMPENSATION OECLAAATION APPLICATION DATE VALUATION PERMIT FEE
•
I hereby affirm under penalty of perjury one of the following declaration:
❑I have end will maintain a CedHlcate of Consent to self-Insure for Workers Compensation, � Building
as provided for by SeUfon 37W of the Labor Code,for Me perfUrnerum of the work for which this (�
peunit I - ued. Rol Seismic
have end will melmon Worker's Compensation Insurance,as recall by Section 3700 of
Me Labor Coale,for the perrormance of Me work for which this permit is Issued.My Workers
Compensation Insurance ca,�t ,a d Policy number are: 06
�c Total 1 � • 2-0Center S Te �j, M Policy No PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need rot be completed If the permit Is for one hurchred dollars($1 DO)or lase.)
I certiry that In the paformatcs of the work for which this permit s I}}yyued aleC not Ivy
any person In any manner So ere to become subject to Me Workers'C(mp ^nation Lawn w�a11- All roofs shall be inspected prior to any roofing material being
fourths. _ \ installed. If a roof is installed without first obtaining an
Dale I )-! ' Applicant Inspection,I agree to remove all new materials for inspection.
suge�a too theOw�ers�T: If,after meMnp this CertificateI or Exemption you should become Applicant understands and will comply with all non point
CIS p permit
s n l be e w of the Leber Coale,you must IordrMM rxxnpty
with each phot I rushave
r MIs his application
ehe11 deemed thatrevoked. SOUTCe regUlatlOnS.
mply Mat1lata and auntyoralentl Mate that the wave Nlarmegan Iscorrect.tfoagree
to hereby
auwiththor ze rep entl county of this dty to a sateto"pon relating to buifolrg caprope don.tsntl All roof cover to be class" or better.
hereby apurip a representatives of this tlry to enter upon the abate-rnerttioretl property for In -�
. (We)agrpoeaa.
(We)spree a save,expenses
and keep harmless Ma City of Cupertino Sold y,inagainstcon Iequen e,
of I a gran costa and expenses which may In any way accrue against saki Gry,in consequence SIGNATURE OF APPLICANT DATE
oft a granting of this permlf.
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: christye
Sec: Twp: RnB: Sub: Blk: Lot:35709049.00
INVOICE DATE...... : 11/05/1999
REFERENCE ID # ... : 99110029
SITE ADDRESS ..... : 10022 SCENIC BLVD
SUBDIVISION ...... .
CITY .. . . . ........: CUPERTINO
IMPACT AREA .......
OWNER . . . .........: ANDERSON
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-2725
CONTRACTOR .......: LIC p
COMPANY . .........:
ADDRESS . . ........:
CITY/STATE/ZIP ....
TELEPHONE ........:
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------""--- -----------
BPERMFEE P 177.00 0.00 177.00
BSEISMICRE P 1.20 0.00 1.20
BUSLIC P 86.00 0.00 86.00
--------- ------------ -----------
264.20 0.00 264.20
ID DESCRIPTION VOICE ID DESCRIPTION
-------- --------------------- -------- ---------------------------.
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS