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99100006E • 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 PERMIT ISSUANCE OR /}, 1 B DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRE�/ �/ � L�� ' //') � �� ' RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA VES ❑ If yes I understand that a Class A NAME roof assembly Is required. NO ❑ � Initial LC.B.O. H EXISTING ROOF COVERING r ADDRESS PHONE _ NUMBER OF EXISTING COVERINGS CONTRACT R'Si f TO BE REMOVED ` TO BE RETAINED NAME ADDRESS il COVERING CITY sZIP—5 EXISTING y/ PHONE _,�S-�- �l BUILT-UP ROOF - LICENSE NUMBER /s ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm Met I am Ikersed under provisions of Chapter 9 (commencing with Section WOOD SHAKES ]000) of Division 3 of the Business ere Professions Coda, and my license is in full force and effect. WOOD SHINGLES ❑ - LkenseCl/ese �_� be. Number QQ,.— L,� OTHER (SPECIFY) ❑ Date J Contractor y OWNER -BUILDER DECLARATION ' I hereby affirm that I am exempt from Me Convectors Ucense Law for the following reason. PROPOSED 0 (Sec. 7031.5, Business are Professions Corte: Arty city or county which requires a parMt to cawtruct, after,improve,combine, or repair any structure, prior to its issuance, also requires the BUILT-UP ROOF El- D appliranl for such permit to file a signed statement that he Is Ilcersseci pursuant to the prwlsbns D of the Contractors Ucerse Law (Chapter 9 (commenclng with Section ]000) of Dlvlaon 3 of the 'I OCT Business and Professions Code) or that he Is exempt therefrom are Me basis for the alleged ASPHALT SHINGLE 'l exemption. Any veketion of Section 7031.5 by sm, applicant for a permit subjects the applicant to - e dyll person, of not more than live hundred dollars (5500).): 1. the their do WOOD SHAKES ❑ C] as owner of property, or rtry, employees with wages as sole cempanaetbn, will the work, and the structure Is rent intended or offered for We (Sec. 7044, Business aro Fieles- By slonsCode: TherontrectorsLicenseLawdoesnotapplytoanownerofpropertywoobu0dsor WOOD SHINGLES Improves thereon, and wbo does such work himself or through his own employees, provided that such Improvements are not intended or offered for solo. If, however, Me bulking or Improvement is sold within one year of completion, the owner -bulkier will have the burden of proving that he did OTHER (SPECIFY) ❑ not build or Improve for purpose of sab.). ❑I, as owner of the property, am exclusively convecting wllh licensed contractors to construct the project (Seo. 7044, Business and Professions Code: The Countesses License Lew, does not PROVIDE I.C.B.O. REPORT NO. appy to an owner N property who hullers or Improves thereon, and woo contracts for such projects with a contractors) licensed pursuant to the Contractor's License Lew. MFGR. INSTALLATION SPECS. ❑ I am exempt under Sec. ,B & P. C. for MIs reason .PROVIDE Owner - Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of p jury one of the following deciaretion:. El I have and will malntain a Certificate of Consent to self -Insure for Workers Compensefion, as provided for by Section 37M 01 the Labor Cade, for the Performance of the work for which this is - // /may pp/ ` BUIIdIn g permll % SeISR11C O" have see will maintain Worker's Compensation Insu., esrequired by Section 3700 of I exerissued. N�ens Cade, far performance of the work for whiU Mie permit is issued. My Workers Total tic Comisensallon Irtturance rarrfar eM Policy number are: t=VS.6%%L Carrier 'e �4 Cz Policy N PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM K E S' - _ COMPENSATION INSURANCE N.CJ] (This section reed not be completed d the permit Is for one hundred dollars is100) or less.) I certify Met In the performance of the work for which MIs permit Is Issued, I shall rot employ All roofs shall be inspected prior to any roofing material being ary Person In erry mourner so as to became subject to the Workers' Compensation Lawn N Cali tared. installed. If a roof is installed without first obtaining an Dale Applicant inspection, I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you slouk become Applicant understands and will comply with all non int pP P Y Po subject to Me Workers' Compensation provislons of the Labor Code, you must forthwith comply with such provksfons or thls peewit shall be deemed revoked. source regulations. . I steely that I have read this application Most state Mat the above Information is correct.) agree to comply with all city and counry ordinernes aro state laws relating to bullding consimction.and All roof coverings to be class "C"or better. hereby auti representatives of this dry to enter upon the above-meniforced property for in- spection purposes. f (We) agree to esus, IroemNn, and keep harmless Mt On, N Cupertino egelust gadlltlm, judgments, costa and expenses which may In any way accrue against said Cry n coasequeroe SIGNATURE PLICA DATE of the granting of this permfl. 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY INVOICE INVOICE• INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE Sec: Twp: Rng: Sub: Blk: Lot:39250012.00 INVOICE DATE......: 10/01/1999 REFERENCE ID p ...: 99100006 SITE ADDRESS ..... : 22999 STANDING OAK CT SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OWNER ............: CHIANG GLORIA K AND MICHAEL M ADDRESS ..........: CITY/STATE/ZIP ...: CUPERTINO CA, CA 95019-2660 CONTRACTOR .......: RUMFORD, LINDY LIC N 3921 COMPANY ..........: LINDY ROOFING CO INC ADDRESS ..........: 5559 HARVARD DR CITY/STATE/ZIP ...: SAN JOSE, CA 95118 TELEPHONE ........: (908)269-2025 FEE DESCRIPTION CHK --------------- --- BPERMFEE P BSEISMICRE P V(' ID _--__---DESCRIPTION FRAME -____ 601 ROOF TEAR OFF 603 ROOF BATTENS —• TOTAL FEE PAID -TO -DATE BALANCE DUE --------- ------------ ----------- 157.00 0.00 157.00 1.00 0.00 1.00 -------- ----------- ----------- 158.00 0.00 158.00 -------- VOICE ID v_- ......PTION ........ ............................ 307 INSULATION 602 ROOF PLYWOOD NAIL 609 ROOF IN -PROGRESS CITY OF CUPERTINO • BUILDING PERMIT INVOICE OPERATOR: karenb Sec: Twp: Rng: Sub: Blk: Lot:39250012.00 INVOICE DATE......: 10/01/1999 REFERENCE ID p ...: 99100006 SITE ADDRESS ..... : 22999 STANDING OAK CT SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OWNER ............: CHIANG GLORIA K AND MICHAEL M ADDRESS ..........: CITY/STATE/ZIP ...: CUPERTINO CA, CA 95019-2660 CONTRACTOR .......: RUMFORD, LINDY LIC N 3921 COMPANY ..........: LINDY ROOFING CO INC ADDRESS ..........: 5559 HARVARD DR CITY/STATE/ZIP ...: SAN JOSE, CA 95118 TELEPHONE ........: (908)269-2025 FEE DESCRIPTION CHK --------------- --- BPERMFEE P BSEISMICRE P V(' ID _--__---DESCRIPTION FRAME -____ 601 ROOF TEAR OFF 603 ROOF BATTENS —• TOTAL FEE PAID -TO -DATE BALANCE DUE --------- ------------ ----------- 157.00 0.00 157.00 1.00 0.00 1.00 -------- ----------- ----------- 158.00 0.00 158.00 -------- VOICE ID v_- ......PTION ........ ............................ 307 INSULATION 602 ROOF PLYWOOD NAIL 609 ROOF IN -PROGRESS CITY OF CUPERTINO T• 1 Of 1 BUILDING PERMIT RECEIPT OPERATOR: karenb COPY # 1 Sec: Twp: Rng: Sub: Blk: LOC:34250012.00 DATE ISSUED.......: 10/01/1999 RECEIPT p.........: 10231 REFERENCE ID # ...: 99100006 SITE ADDRESS .....: 22999 STANDING OAK CT SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OWNER ............: CHIANG GLORIA K AND MICHAEL M ADDRESS ..........: CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-2660 RECEIVED FROM ....: JOE S CONTRACTOR .......: RUMFORD, LINDY LIC 4 3921 COMPANY ..........: LINDY ROOFING CO INC ADDRESS ..........: 5554 HARVARD DR CITY/STATE/ZIP ...: SAN JOSE, CA 95118 TELEPHONE ........: (408)269-2025 FEE ID UNIT QUANTITY AMOUNT PD -TO -DT THIS AEC NEW BAL -------------- ---------- ---------- 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 4658 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