99090119to
I
08.3 /gig Y0//t?• PERMIT,
APPLICATION FORCITYOFCUPERTINO NUMBER
REROOF PERMIT INSPECTION (DlvlsloN PERMIT EXPIRATION
408) 77I-9228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN DAYS PERMIT ISSUANCE OR
- DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
C1r� �
19 � 9s'
I.Sfcun
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
I HAZARDOUS FIRE AREA
/,J' y�
VES ❑ If yes — I understand that a Clens A
NAME D 6O�L / r ^2%
roof assembly is required.
NO ❑ Initial I.C.B.O.N
--�_J
� ` �
EXISTING ROOF COVERING
ADDRESS / "' ' 1, 4H.rLr�A
J,
PHONE 037
NUMBER OF EXISTING COVERINGS
CONTAAC OR'S - I
\ I
N IL
TO BE REMOVED TO BE RETAINED
ADDRESS/
L
TYPE OF ROOF COVERING
CITY & ZIP X7-0 \YNC'OLy.
EXISTING ,
PHONE 29S-&ji
BUILT-UP ROOF
LICENSE
NUMBER
ASPHALT SHINGLES
LICENSED CONTRACTORS DECLARATION
hereby, affirm that I em licensed under Professions
o Chapter 8 (commencing with rce add
]000) of Division 3 of the Buelmsa end Prolesslons Cote, and rrry license Is In full berm antl
effect,
_
��
WOOD SHAKES
WOOD SHINGLES
License Class Uc. Number -
/-7-
71
THER (SPECIFY)
Data Conirador -
OWNER -BUILDER DECLARATION
PROPOSED
I hereby affirm brut I am exempt from the Contractors License law for the kriosing reason.
(Sec. 7031.5, Business entl Professions Code: Any city or county which requires a permit to
con strum, alter, Improve,demolish, or repW
air any scture, prior Iss
to us uance, also requlres the
BUILT -UPR Q 1
applicant for such permit to file a signed statement that he is licensed pursuant to the prodsbns
I
of the Contractor's License Lew (Chapter 9 (commencing with Section ]000) of Dlvlslan 3 of the
Business and Professions Code) or Met he is exempt therefrom and he basis for the alleged
ASPHALT S GL.`i ES
atlan of Sacticn7031.S by any applicant for a parmh subjects the applicant to
exemption. Any vbnorN
a civil "natty of nmore en Rve hundred dollars
J},l {� 1
7 19th
($500).):
C] 1, as owner of the property, a my lmptoyees with wages as their sole mmptoudon, will do
WOOD SH ES
he work, and the structure is not intended Or offered for sale (Sec. 7044, Business ars Proles -
stns Code: The Contractors License Law does not apply to an "net of property who builds or
WOOD SH t CxES
Marson, and who does such work himself or through his own employees, provided Mei
ElImproves
such improlements are net intended or offered for said. It, however, the building or improvament
Is sold within one year m compbikm, loss owner -builder will hew the bureen of proving that he did
OTHER
(SPECIFY)
not build or improve b purpose of sale.).
_
❑ 1, as owner of flue property, am exciuslyely contracting with licensed contractors to carmtruct
the project (Sec. 7044, Business orer Profeaslona Com: The contractors license law does not
PROVIDE I.C.B.O. REPORT NO.
appy to an owner of property who builds or Improves thereon, and who contracts for such projects
; with a contractogs) licensed pursuant to the contractors Jocose Law.
36 �
❑ 1 son exempt under Sec. ,B & P. C. for this reason
PROVIDE MFGR. INSTALLATION SPECS. r
Owner
Data
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby shim under penalty, of perjury one of the following declaration:
❑ 1 have and will winter a CerflflcMe of Consent to self -insure for Workers Compensation,
this
as provided br by Section 3700 of Me LCode, blhe rperformance of the workkx which9/
/
Building
Perin isLssood.
ve entl will maintain Worker's ComPeruaflon Insurance, as required by Section 3700 d
/%///-'?7
Seismic
Labor Code, for the performance of the work for which this permit Is Issued. My Workers
Corrpenseuon nsurce center imdU number are
Total
_
1L �y
PERMIT AUTHORIZATION
DATE
Carder - PoicyNrxrM2 Lf
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C[]
Finds section need not m completed Ifthe permit Is for one hundred dollars ($100) or less.)
(Thsectionany
I curtly met in the Performance of the work for which floe panJt Is Issued, I shall not emW oy
In
person cry ner so as to become eubje a Workers' c mPensaflom laws of Ce11-
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an•
DateAPp
inspection, I agree to remove all new materials for inspection.
NOTI E TO PDCAM: If, eller t rflflm 1 mmpibn, you atwuM become
subject to the workers' Compensafl°n provisions of flue L , you must forthwith campy
AP ant understands and will comply with all non point
with such provisions or this Permit shall be marded =" - _
source r Iations.
I curtly Mat l have read Offs application and state that the above information is cones Iagree
AI
to comely with all city and county ordinances end state laws relating to baildbg construction, and
o verings to be lass"C°or better.
hereby 8IAh0rize rapresenMWes of this city to anter upon the above-mentioned property kx in-
spected purposes.
(We) agree to save, Intlamnlly and kedge hennesa Me City of Cupertino against fabling",7
Iu nts, mels and expenses whichy, b maany way aooue against said Gty In consequence
of granting of this permit.
URE ICANT DATE
PRE -INSPECTION:
PLYWOOD: -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
OFFICECOPY
CITY OF CUPERTINO
I'• 1 of 1 BUILDING PERMIT RECEIPT
Sec: Twp: Rng: Sub: Blk: Lot:36906009.00
DATE ISSUED.......: 09/17/1999
RECEIPT q.........: 10109
REFERENCE ID # ...: 99090119
SITE ADDRESS .....: 19G24 STEVENS CREEK BLVD
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: nancyc
COPY 4 : 1
OWNER ............: TCW REALTY FUND III HOLDING CO
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014
RECEIVED FROM ....: ALAN DORSETT
CONTRACTOR .......: LIC H
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP ....
TELEPHONE .........
FEE ID UNIT
BPERMFEE VALUATION
BPLANCHK PERMIT FEE
BSEISMICRE VALUATION
I&PERMIT :
METHOD OF PAYMENT
CHECK
TOTAL RECEIPT
QUANTITY AMOUNT PD -TO -DT THIS RED NEW SAL
---------- ------------------------------ ----------
42,000.00 436.00 0.00 436.00 0.00
1.00 62.25 0.00 62.25 0.00
42,000.00 4.20 0.00 4.20 0.00
502.45 0.00 502.45 0.00
AMOUNT
------------
502.45
............
• 50245
VOICE ID DESCRIPTION
....................
305 FRAME
601 ROOF TEAR OFF
603 ROOF BATTENS
NUMBER
------------------
0341
VOICE ID DESCRIPTION
....... ........ ...................
307 INSULATION
602 ROOF PLYWOOD NAIL
604 ROOF IN -PROGRESS
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE .INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: nancyc
Sec: Twp: Rug: Sub: Blk: Loc:36906009.00
INVOICE DATE......: 09/17/1999
REFERENCE ID # ...: 99090119
SITE ADDRESS .....: 19624 STEVENS CREEK BLVD
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: TCW REALTY FUND III HOLDING CO
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014
CONTRACTOR .......: LIC 4
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP .... ,
TELEPHONE ........:
FEE DESCRIPTION CHK
TOTAL FEE
PAID -TO -DATE
BALANCE DUE
_______________ ___
SPERMFEE P
---------
436.00
------------
0.00
_____-_____
436.00
BPLAN CHK A
62.25
0.00
62.25
BSEISMICRE P
4.20
0.00
4.20
_________
502.45
____________
0.00
___________
502.45
V ID-.-.'_- DESCRIPTION---_-----
VOICE
ID
FRAME
307
--DESCRIPTION
INSULATION
601 ROOF TEAR OFF
602
ROOF
PLYWOOD NAIL
603 ROOF BATTENS
G04
ROOF
IN -PROGRESS
0