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990901463- W901 ' PERMIT APPLICATION FOR CITY OF CUPERTINO NUMB REROOF PERMIT INSPECTION DIVISION ERMIT EXPIRATION (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 1W DAYS OF PERMIT ISSUANCE OR 1 W DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS 2 C7 Z SC/ (J,r_7 RESIDENTIAL COMMERCIAL OTHER OWNER'S NAME p ADDRESS �`' 11 `D U / 'S U A/ (� (fL)n CR 1 /N UUN I HHl.I UN J '. `l NAME J (,1 r, Jam` { / /� C1DTY,&ZIPn 2 T ..J 0 U !�N LICENSE NUMBER I hereby afllnn that I am licensad under provlslon , of Chapter 9 (comini with Section ]000) of Division 3 of the Business and Professions Code, and my Ilconse Is In lull brae and effect. Date rqIIIIIIIII - for the following reason. qul res a permit to also requires Ne tLnslnee9'antl Yroiasswrw Ca Oe) or trust he is avempt therefrom arM the basis for the alleged axemptio Maw 1 ppllcantto e c7 p o t r ❑ L as I eye SO' tion, will do Ne work, I r f sl nd Pnofes- dons Code: The Conimcto'o app y to an ho bundsor improves thereon, and who does such work himself or through his own employees, provided that such Improvements are not Intended or offered for sale. If, however, the building or Improvement Is sold within orm year of completion, the owner4nullder will have the burden of priming that he tlb not builtl�r improve for purpose of sale.). ' IrjI ownerofthe property, am excAuslvety, contracting with licensed contractors to comoruG the protect (Sec. ]Dad, Business and Pmfessbns Code: The Contractor's License Law does not appy to an owner of property who Wilds or Improves thereon, and who connects for such projects with a contactor(s) licensed pursuant to the Contractors License Law. em exam t untler Sec. ,B & P. . br this eeson rTw^^r D t WORKER'S COMPEf SATION DECIARATION - I hereby affirm under penalty of perjury one of the following federation: ❑ 1 have and will maintain a Cerllficate of Consent to self -Insure for Worker's Compensetlon, as provided for by Section 37W of the Labor Code, for the pedormance of the work for which this permit is issued. ❑ I hicee end will maintain Worker's Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit Is Issued. My Workers Compensation Inwrence carder and Policy number are: Cartier Pcllcy No. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.CQ (This section need not be completed If the permit is for one hundred dollars ($100) or less.) I comity that in the performance of the wc4, for which this permit Is Issued, I shall not employ any parson In any manner so as to become subject to the Workers' Compensation Laws of Can- fori -Date Applicant NOTICE TO APPLICANT: If, after making this Cannibals of Exemption, you shoukf became subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. I certifythou I have read thk eppllcatbn and state that the abmb Information is correct.I agree to comply worn all city and count' ordinances and state laws relating to Wlltling construction, and hereby authorize representefives of rnle city to enter upon the above -m ntloned property far in- spectlonpurposes. (We) agree to save, Indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way acme against said City In consequence of the granting of this permh. PRE -INSPECTION: PLYWOOD: INSP. DATE INSP. DATE TEAR OFF INSPECTION: BATTENS: DATE I INSP DATE YES ❑ - If yes – I understand that a Class A roof assembly is required NO ❑ Intl I.C.B.O. R - NUMBER OF EXISTING COVERINGS TO BE REMOVED TO BE RETAINED TYPE ERIN rAMPTING / BUILT-UP ROOF ASPHALT SHINGLES WOOD SHAKES ❑ WOOD SHINGLES ❑ OTHER (SPECIFY): Pa t PROPOSED BUILT-UP ROOT Slip 2 4 Q99 ASPHALT SHINICTLES Coli WOOD SHAKE- By❑_ WOOD SHINGLES . ❑ OTHER (SPECIFY) ❑ PROVIDE I.C.B.O. REPORT NO. PROVIDE MFGR. INSTALLATION SPECS APPLICATION DATE VALUATION PERMIT FEE - Building / ( Seismic / Total PERMIT AUTHORIZATION DATE ,%y -Z!/ 91111< All roofs shall be ins(dected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove all new materials for inspection.. Applicant understands and will comply with all non point source regulations.. All roof coverings to be U1wGttw_n elclass "C" or better.14 / 1^, JLx U ale `bwl99 IMM -1111111 NOTE: OSHA -APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY • CITY OF CUPERTINO PD -TO -DT Item 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: yv=n ek 0.00 12,000.00 1.20 COPY # 1 0.00 Sec: Twp: Rng: Sub: Blk: Lot:36928015.00 20 0.00 DATE ISSUED.......: 09/24/1999 RECEIPT N.........: 10152 REFERENCE ID q ...: 99090146 SITE ADDRESS .....: 20211 SUISUN DR SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA ....... OWNER ............. RANGWALA JUMANA Z AND ZOAIB ADDRESS ..........: 20211 EDISON DR CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4427 RECEIVED FROM ....: TIM CONTRACTOR .......: LIC k COMPANY ..........: ADDRESS ..........: CITY/STATE/ZIP .... TELEPHONE ........: FEE ID UNIT BPERMFEE VALUATION 114ICRE VALUATION TOI PERMIT : METHOD OF PAYMENT ----------------- CHECK QUANTITY AMOUNT PD -TO -DT ------------- 12,000.00 ---------- 177.00 ---------- 0.00 12,000.00 1.20 0.00 170 20 0.00 AMOUNT NUMBER 17B.20 ------------ ------------------ 145 TOTAL RECEIPT 178 VOICE ID DESCRIPTION ........ ..................... 305 FRAME 601 ROOF TEAR OFF 603 ROOF BATTENS THIS REC NEW DAL --------- ---------- 177.00 0.00 1.20 0.00 ---------- 178.20 0.00 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: yvonnek Sec: Twp: Rng: Sub: Blk: Lot:36928015.00 INVOICE DATE......: 09/24/1999 REFERENCE ID N ...: 99090146 SITE ADDRESS .....: 20211 SUISUN DR SUBDIVISION ......: CITY .............: CUPERTINO IMPACT AREA ....... OWNER ............ : RANGWALA JU14MA Z AND ZOAIB ADDRESS ..........: 20211 SUISUN DR CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4427 CONTRACTOR ... .... : LIC # COMPANY ..........: ADDRESS ..........: CITY/STATE/ZIP .... TELEPHONE ........: NOTE: THE FEES LISTED ARE ONLY THOSE DUE BEFORE PERMIT PRINTING FEE DESCRIPTION CHK TOTAL FEE PAID -TO -DATE BALANCE DUE --------------- --- BPERMFEE P --------- 177.00 ------------ 0.00 ----------- 177.00 BSEISMICRE P 1.20 0.00 1.20 •178.20 0.00 178.20 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