99100034 3 5 9 LS qq Ito 3
APPLICATION FOR CITY of CUPERTINO
REROOF PERMIT INSPECTION DIVISION PERMIT ERP,RATION
(408)]T)-(j'jl'B PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
/63 a Al ` '/{ RESIDENTIAL
COMMERCIAL OTHER
OWNER'•SS HAZARDOUS FIRE AREA
�' �`�. ///� - - YES ❑ II yes-I understand that a class A
NAME �+���-^�A''�J-�+� 'loot assamWy Is required.
NO ❑ Initial I.C.B.O.N
`jam EXISTING ROOF COVERING
ADDRESS -f -1`C
PHONE r / Ll I ZO NUMBER OF EXISTING COVERINGS /
CONTRALTO
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS
' � TYPE OF ROOF COVERING
CITY&
EXISTING
PHONE'l SOJ 7 [ 3 —63 73 BUILT-UP ROOF
LICENSE
NUMBER 2 O V ASPHALT SHINGLES ED
DCENSED CONTRACTORS DECLARATION
I hereby efflo,that I am licensed under provisions of Chapter 0(commencing with Section WOOD SHAKES
]000)of DNlslon 3 of the Business and Professions Code,entl my license is in full force and;
effect. n
7 WOOD SHINGLES O�y
Odense Claes Dc.Number �9
/0OTHER(SPECIFY)
Det. Contractor
ONNER-BUILDER Dtors UcTIO PROPOSED
hereby affirm that em exempt from the Contractor's License Lew for the requires
a following reason.
(Sec.Tct,alt,r,Ip'Business and demolish,
or rai Coda: Any city or oounty which requires a ui res ai �../
applicant for
Improve,demolish, n d!stn any structure,the prior to0ItOrr Its issuance,also requires the BUILT-UP ROOF 7}
applicant for each permit a his a signed statement Net fc i h e Section
pursuant to the provisions T
of the ss and tare License Law,(Chapter h(commencingg with om am the b offorClhe 3 le ed
Business end tolaesbty Cada)or that he is exempt therefrom am the basisforthe applicant
ASPHALT SHINGLES ❑
axeallper Any violationof Section 7031.5 by any applicant fora permit eublecls the applicant to
e civil parralry of not more than five hundred tlolmro($500).):
❑I,as owner of Ne property,or my employees wlN wages as their sots compensation,will do WOOD SHAKES ❑
the work,entl the structure Is not Intended or offered for sale(Sec.7044,Business am!Plane.
skins Core:The Conlracloes License Lew does not apply to an owner of property who oulds or WOOD SHINGLES ❑
improves thereon,and who does such work himself or through his own employees,otmided that
such improvements are not Inlemed or offered for sale.If,howaveq the building or Improvement
is sold within ome year of compotlon,are owner4lullci will have the burden of proving that he did OTHER (SPECIFY) ❑
not build or Improve for purpose of vale.).
❑1,as Owner of the property,am exclusively contracting with licensed contractors to construct
Me project(Sec.7044,Business and Professions Code:The Contractor's Licenea Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or irtpro,es thereon,entl who contracts ior such projects
with a warnector(e)licensed pursuant to the Contractors Ucense Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sec. ,B E P.C.for luta reason
Owner Date
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm undor penalty of perjury one of the Idlowlng declaration:.
'❑1 have and will maintain a Certificate of Consent to self-Insure for Workers Compeneatlon, Buildi /d7•
as pravltlad for by Section 3700 o1 the Labor Code,for the performance of Ne work for which this ng
pe�Jlt la Issood
�(l I have and will maintain Wohale Comperwelbn Insurance,as required by Section 3700 of /' 7 Seismic '
ih Labor Code,for the performance of the work ka witch tints peones Is Issued.My Workers 1-z
mpensabon I arra carrier end Polley rermber ere: ` ` Total I0" .. 5 Q
Carrier ��-"�-- Palk"No.s?1- F?-//z5 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need nor be completed If the permll Is for one hundred dollars($100)or Ines.)
I carry that In the performance of the work for which this permll Is Issued.I shall not employ
any person In any manner so as to b.rnme subject to the Workers'Compensation Laws of Call- All roofs shall be inspected prior to any roofing material being
forma. installed. If a roof is installed without first obtaining an
Data 9 Applicant Inspection,I agree to remove all new materials for inspection.
UCAM:
NOTICE TO APPIf,atter mekeg lids Carulica of Exemption,you should become Applicant understands and will I with all ort
subject to the Workers'Compensation provision ,yco
of the Labor Code, must forthwith mply PP coin- P y wanon P
with srxh provisions or this permit shell be deemed revoketl. . source regulations.
I certify that I have read thin application and state that the above information Is coned.I agree
to camply with all city and county ordinances am state laws relating to building construction,and All roof coverings to be cls Or better. .
hereby authorize representatwes of this city to enter upon the above-mentioned property for in-
spectral purposes. -
(We)agree to save,indemnity and keep harmless the City of Cupertino against ilabllWes, ! I /
jwgments,mate and expenses witch may In any way accrue against said City In
a granting of do,perms. cansequerce SIGNATOR F APPLICANT DATE
of
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: chrietye
Sec- Tp: Rng: Sub: Blk: Lot:37524015.00
INVOICE DATE......: 10/07/1999
REFERENCE ID # ...: 99100034
SITE ADDRESS ..... : 10324 STERLING BLDG
SUBDIVISION ...... .
CITY . . . .......... : 0
IMPACT AREA .......
OWNER . . .......... : SCHLAGITER
ADDRESS . ......... :
CITY/STATE/ZIP ... : 0, CA 95014
CONTRACTOR .......: COSMOS, RICHARD LIC q 18844
COMPANY ..........: COSMOS ROOFING
ADDRESS .......... : 450 SAN ANTONIO RD
CITY/STATE/ZIP ... : PALO ALTO, CA 94306
TELEPHONE ........ : (415)493-6373
FEE DESCRIPTION CHT( TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPERMFEE P 107.00 0.00 107.00
BSEISMICRE P 0.50 0.00 0.50
. "'------ ------------ ""'-------
107.50 0.00 107.50
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
I* 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: christye
COPY k 1
Sec: Twp: Rng: Sub: Blk: Lot:37S24015.00
DATE ISSUED.......: 10/07/1999
RECEIPT q. . .......: 10263
REFERENCE ID # ... : 99100034
SITE ADDRESS .....: 10324 STERLING BLDG
SUBDIVISION .......
CITY .. ...........: 0
IMPACT AREA .......
OWNER . . .......... : SCHLAGITER
� ADDRESS .......... :
J
CITY/STATE/ZIP ... : 0, CA 95014
RECEIVED FROM .... : TIM
CONTRACTOR ....... : COSMOS, RICHARD LIC b 18944
COMPANY ........ . . : COSMOS ROOFING
ADDRESS ...... . . . .: 450 SAN ANTONIO RD
CITY/STATE/ZIP . ..: PALO ALTO, CA 94306
TELEPHONE .... . . . . : (415)493-6373
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- --------'
BPERMFEE VALUATION 51000.00 107.00 0.00 107.00 0.00
BS SMICRE VALUATION 4,140.00 0.50 0.00 0.50 0.00
1d PERMIT 107.50 0.00 107.50 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 107.50 10383
�.
----••
TOTAL RECEIPT 107.50
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ----------------------------
305 FRAME 307 INSULATION
6b1 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•