99090171 =NBE
APPLICATION FOR CITY OF CUPERTINO
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
(408)rn-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
fall DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
�/Ste- SC's( /a�-r� ��,•
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ N yes—I understand that a Class A
NAME �� WSrj�� root assembly is required.
J J�AA NO ❑ Initial I.C.B.O.#
ADDRESS &:S z �/ J , EXISTING ROOF COVERING
PHONE
_ NUMBER OF EXISTING COVERINGS
CONTRACTOR'S ; t
TO BE REMOVED O BE RETAINED
NAME
ADDRESS c 1_�. Ali
TYPE OF
CITY 8 ZIP D� /.Ifir V`.c l �/
// a o EXISTING /1
PHONE 7Oi e�,1sP.rL� BUILT-UP ROOF / 2
LICENSE
NUMBER / ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION !/l 11 11
I hereby strum that I am liminsed under provisions of Chapter 9(commencing with Section WOOD SHAKES '5 ❑ I
7000),of Division 3 of the Buslnew and Professions Code,and my license Is In full force and II 11 ,
effect. WOOD SHINGLESI p 2 01999 II
Llcanee Clew `� � Dc.Number SE v
OTHER (SPECIFY)w ❑
Date Contractor L T
Dai ' OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the contractors License Law for the IolbvHkg reason. PROPOSED By
(Sec 7031.5,Business and Professions Code: Any city or county wall requires a permit to
construct,after,improve,denal or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to file a elgrod statement Net he Is licensed pursuant to the pmviaions
of the Contractors License Lew(Chapter 9lcoameming with Section 1000)of Drdsln 3 of the
Business and Professions Cade)or that he Is exempt Merefrom and Ne basis for the al'i .ASPHALT SHINGLES
exemption.Any violation of Section 1031.5 by any appllant for a permit subjects the appllcont to
a cMI penalty of not more than five hundred dollars(5500).):
❑I,as ownerof the property,or my employees with wagon as i sole compensation,will do WOOD SHAKES ❑
the work,and the structure Is not Intended or offered for sale(Sec.1044,Business and Profes-
sions Code:The Contractor's Lima"I.aw does not appy to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who toes such work himself or through his own employees,provided that ❑
such Improvements are not Intended or offered for sale.If,however,The butting or Improvement
Is sad within one year of completion,the owner-bulkier will have the burden of proving Met he did OTHER(SPECIFY) El
Wild or Improve for purpose a able.).
❑I,as owner of the property,em exclusively,contracting with licensed carawoks to construct
the prolml(Sec.7044,Business and Professions Cole:The Contractor's Ucense Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or improves Thereon,and who contracts for such projects
with a conaaaor(s)licensed pursuant to the Contractors License Lew.
❑I am exempt under Sec. ,B 8 P.C.for this reason PROVIDE MFGR.INSTALLATION SPECS.
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑1 have and will maintain a Certificate of Consent to self-Insure for Worker's Compensation, _ Building
as provided for by Section 3100 of the Labor Code,for the performance of the work tar which this
peal s Massed. f �c�' 7 25 Seismic
t have and will maintain Workers Compensation thermal as requtred by Section 3100 of
the labor Code,for the padomrnm of the work fon which this permit is issued.My Workers
Compensation InsurerXs ca vier and Polly number rel: [�� .4I Total ILL-7
_�_,_�
Center !=u PoxcyNo.� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CL] �-/
(Thin section need not be completed If the Permit Is for ore hundred dollars($100)or less.) Tb
I codify Met In the performance of the work To which Thu permit is issued,I shall not employ
any person In any manner so as to become subject to the Workers'Compensation Laws of Cali- All roofs shall be inspected prior to any roofing material being
fomla. - Installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: If,after Malang this Celificam of Examptlon,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisklls of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permN shall ba deemed revoked. source regulations.
I carry,Met I have used Mile application and state that the above information Is murecl.I agree
to comply,with all dry and munry oncharroae and sure laws relating to building construction.al All roof coverings to beccAclmass //o,'o[[batt r.
hereby authorize represenetives of this sty to enter upon the ebovemonibrotl property or In- /1 �
(Wel agree to save.Memnity said keep harmless The Gry of Cupertino against liabilities,
judgments,costs and expenses~may in any way accrue against said CityAll io consequence
of the granting of Thu permit. SIGNARM€OF P ICAN DATE
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: christya
Sec: Twp: Rng: Sub: Blk: Lot:36228010.00
INVOICE DATE......: 09/28/1999
REFERENCE IO # ... : 99090171
SITE ADDRESS ..... : 1152 SCOTLAND DR
SUBDIVISION ...... .
CITY ... . . .1...... : CUPERTINO
IMPACT AREA ...... .
OWNER . ........... : WOLSER THEODORE L AND SHIRLEY
ADDRESS ..........
:
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-5026
CONTRACTOR . . . . ...: RUMFORD, LINDY LIC M 3921
COMPANY .. . . . .....: LINDY ROOFING CO INC
ADDRESS 5554 HARVARD DR
CITY/STATE/ZIP ... : SAN JOSE, CA 95118
' TELEPHONE . . . ..... : (408)269-2025
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
V ID ----___-DESCRIPTION_-------. VOICE ID - DESCRIPTION
-- -------- ------ -----------------
FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
CITY OF CUPERTINO
1 of 1 BUILDING PERMIT RECEIPT OPERATOR: christYa
COPY N 1
Sec: Twp: Rng: Sub: Blk: Lot:36228010.00
DATE ISSUED.... . . . : 09/28/1999
RECEIPT M..... . . . . : 10168
REFERENCE ID N . . . : 99090171
SITE ADDRESS . . ...: 1152 SCOTLAND DR
SUBDIVISION . . . ....
CITY ....... . . . .... CUPERTINO
IMPACT AREA . . .....
OWNER ... . . . . .....: WOLBER THEODORE L AND SHIRLEY
ADDRESS . . . . ......:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-5026
RECEIVED FROM ....: TIM
CONTRACTOR . . .....: RUMFORD, LINDY LIC 4 3921
COMPANY .... . .....: LINDY ROOFING CO INC r
ADDRESS ... . . . ....: 5554 HARVARD DR
CITY/STATE/ZIP ...: SAN JOSE, CA 95118
TELEPHONE . . ...... : (408)269-2025
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
-- ------ ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 9,000.00 147.00 0.00 147.00 0.00
BICRE VALUATION 9,000.00 0.90 0.00---------- ------0_90 ------0-00
At PERMIT : 147.90 0.00 147.90 0.00
METHOD OF PAYMENT AMOUNT NUMBER
____ - ------------ ------------------
CHECK 147.90 VISA
------
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