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9910035 357 o 7 W100065 P 3 APPLICATION FOR CITY OF CUPERTINO N r REROOF PERMIT INSPECTION DIVISION PERM IT EXPIRATION (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED ' WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM VST CALLED INSPECTION, BUILDING ADDRESS RESIDENTIAL COMMERCIAL - OTHER_d— OwNER'SJ/^ 1 1 /� HAZARDOUS FIRE AREA - NAME `f�=/ 0_4A 1 l S 4_ l YES ❑ � sm"y i laMr��a C18ss A NO ❑ Initial I.C.B.O.i ADDRESS -S 0. EXISTING ROOF COVERING PHONE X NUMBER OF EXISTING COVERINGS , CONTRA/CT nA �� l_4.Q. M 0&4!- 1• TO BE REMOVED / OBE RETAINED _l NAME ; ADDRESS FrOVE yy-�ne D GITV 8 ZI I TI O/� o PHONE ! A 33 BUILT-UP ROOF LICENSE NUMBER - ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby af8nn that 1 ani licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES 7000)of DMalon 3 of the Business arM Professions Code,and my license Is In full force and affeLt. WOOD SHINGLES ❑ ucense clava 1.c3 q uc.Number Date Contmno. OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm Met I am exempt from the Contractor's Ucense Law for the following reasp (Sec.7031.5,Business and Professional Code: Any dry or county which requires a permit to construe,alter,Improve,deal or repair any structure,prior to 0 satuance,also requires the BUILT-UP ROOF ❑ applicant for such permit to file a signed statement that he Pa licensed Pursuant to the provlslons of the Contractors License Law(Chapter 9(commencing with Section 7000)of DMskn 3 of the Business and Profes000e Code)or that he la exempt therefrom and the heels for the alleged ASPHALT SHINGLES ❑ exemption.Any violation of Section 7031.5 by any applicant for a Permit subjects the applicant to a CMI penalty of not more Man live hundred dollars(550014: EJ 1.as owner of the property,or my employees with wages as Meir sole compensation,will do WOOD SHAKES the work,and the structure is not intended or offered for sale(Sac.70",Business and Profes- sionsCode:The Contractors License Law dose not appy to an owner of property whobulldeor WOOD SHINGLES Improves thereon,end who does such work himself or through his own employees,presided that El such Improvements are not intended or offered for sale.If,however,Me Wilding or Improvement Is sold witha one year of completion,the owner-W1Mer will have Me burden of proving Mat he diol OTHER (SPECIFY) ❑ not WIMI or Improve far purpose of eels.). ❑I,as owner of the property,am exciusA•eiy contract rq with lkensed corralto crose l the project(Sec.7061,Business and Professions Cade:The Contractors License Lew dose not PROVIDE I.C.B.O.REPORT NO. apply to an owner of property,who cards or Improves thereon,end who contracts for such projects with a contracloge)ficensed pursuant to the Comraciorb License Law. PROVIDE MFGR.INSTALLATION SPECS. ❑1 am exempt under Sac. ,B&P.C.for this meson Owner oats WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under Welty Of perjury one of the following declaration: ❑I have and will malntaln a Certlllcate of Consent to selbineure for Workers Compensation, Building as provided for by Section 3700 of the labor Code,for the"Hermance of the work for which this permit Is Issued. $eISmIC ❑1 have and will maintain Worker's Compensation Insurance,as required by Sectlon 3700 of the Labor Code,for the performance of the work for which this permit Is Issued.My Worker's F700 CTOta/I� Ompen Ifonl neurance semen en`dicy'�''-mbar _ OarHet P�� "Q 'rcyNO.�� PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N � — (This sectioned not on rebe completed a the permit b on for e huMreO dollars($1000))or lees.) I certify that In the performance of 9e work for which MU permit is Issued,I shall rest employ any person In erry manner so as to become subject to the Workers'Compeneatlon Laws of Cell- All roofs shall be inspected prior to any roofing material beim fornix. 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: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point subject to Me Workers'Compensation provisions of the Labor Code,you must forthwith comply with Such provisions or this Permit shelljbe deemed revoked. - source regulabons. I nearly that I have read this application arM state that Me above Information le correct.I agree to comply with all city and county ordinances and state laws relating to bullding construction,and All roofrigs to be Class or better. hereby.authorize representatives of aria city to enter upon the abed ove-mentionproperty for In- Op/yQp�� spitpurposes. (We) (We)agree tos save,Indemnify w ich keep harmless the e a of against sold Ci apelnst IIebIIX.... r Judgments,eras,costs and expenses which they In any way accrue epalnst sold Ciry In consequence - SIGNATURE OFA ICA DATE of the gmntlrg 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 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: nancyc Sec: Twp: Rug: Sub: Blk: Lot:35707019.00 - INVOICE DATE.... . . : 10/07/1999 REFERENCE IO # . . . : 99100035 SITE ADDRESS .... . : 10434 SCENIC CT SUBDIVISION ..... . . CITY .. . .......... : CUPERTINO IMPACT AREA ...... . OWNER . . . ........ . : BAUTISTA DONALD JR AND ALICE M ADDRESS . ...... .. . : CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-2765 CONTRACTOR ..... . . : RADONICH, GARY LIC N 17814 COMPANY . ........ . : IAS GATOS ROOFING ADDRESS . ....... . . : 1771 SMITH AVE CITY/STATE/ZIP . . . : LOS GATOS, CA 95030 TELEPHONE .... . . . . : (408)358-1233 FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE --------------- ___ --------- ------------ ----------- BPERMFEE P 147.00 0.00 147.00 BSEISMICRE P 0.90 0.00 0.90 --------- ------------ ----------- 147.90 0.00 147.90 •E_ID -------DESCRIPTION -____--- VOICE ID ---'--- DESCRIPTION ¢ .. . ...... ........ ........ 305 FRAME 30] INSULATION 601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 603 ROOF BATTENS 604 ROOF IN-PROGRESS CITY OF CUPERTINO I 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: nancyc COPY # : 1 Sec: Twp: Rug: Sub: Blk: Lot:35707019.00 ' DATE ISSUED... . . . . : 10/07/1999 RECEIPT 4....... . . : 10262 REFERENCE ID # . . . : 99100035 SITE ADDRESS .... . : 10434 SCENIC CT SUBDIVISION ..... . . CITY . . . . . ........ : CUPERTINO IMPACT AREA ..... . . OWNER . . . . . . . ..... : BAUTISTA DONALD M AND ALICE M ADDRESS . . . . . . .... : CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-2765 RECEIVED FROM . ... : TIM CONTRACTOR . . . .... : RADONICH, GARY LIC # 17814 COMPANY . . . . . . . ... : LOS GATOS ROOFING ADDRESS ... . . . . ... : 1771 SMITH AVE CITY/STATE/ZIP ...: LOS GATOS, CA 95030 TELEPHONE . . . . . . ..: (408)358-1233 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REG NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- BPERMFEE VALUATION 9,000.00 147.00 0.00 147.00 0.00 SMICRE VALUATION 9,000.00 0.90 0.00 0.90 0.00 AL PERMIT 147 90 0.00 147.90 0.00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ ------------------ CHECK 147.90 6286 ------...... TOTAL RECEIPT 147.90 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 •