99090186 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBS
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (ao6)n7-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1S0 DAYS OF PERMIT ISSUANCE OR
1B0 DAYS FROM LAST CALLED INSPECTION.
BUILDINGADDRESS
RESIDENTIAL COMMERCIAL OTHER
OWNER'S _ HAZARDOUS FIRE-AREA
, /P ✓ YES ❑ Ies-I understand that a Class A
NAME Al./ C- FSC V .1yt e-ssemWy is required:
Q NO Initlal LC.B.O.B Ll GS G
ADDRESS 7 a 7( .S T'G✓t :k6a LA - .-✓to r EXISTING ROOF COVERING
PHONE O p NUMBER OF EXISTING COVERINGS L
CONTRACTOR'S ,rte,.,J J/• / Q ,.
NAME /���! �"vr, �NS A 11�T77�'V TO BE REMOVED TO BE RETAINED
ADDRESS /� TYPE OF ROOF COVERING
CITY&zip 7MY/��S aA) • .S• !"� 7 1 07.
EXISTING
PHONE �!'4l -777 — 2 3 BUILT-UP ROOFLICENSE
D
NUMBER ASPHALT SHINGLES r`
LICENSED CONTRACTORS DECi-ARATION'
I hereby ahlen that I am Ilcensed under proyisims of Chapter 9(commencing wits Section WOOD SHAKES
]ODD)of Dlvlskn 3 of Me Buslneas and Professions Code,and my Ikense Is In full force and
a 1
men. O WOOD SHINGLES'
Ucaow LJ
Class c.Number z l
�y/cz
pp S_ OTHER�(SPECIFY) n ) `
Date ��L � Contractor 1 I
Oal from
ON PROPQ41'v 2 g 1999 'll 1�
I hereby affirm u met am exempt from ere s Any dy or coup Lew for re browing reason. ` `'�``�'r SEP
(Sec.7031.5,Business and demolish,
sonp Code: Arty dry or county whbh requires e permit to U
wreWntforsafter.Improve,to file ssind any that he
prior to Nelamrance,talso otheequires the BUILT-UPIROOF - ❑
of the Ctforsuchpermit anto flaw asignedstatementthathetsIkeneetl punuanf tothepr 3 of
of the Contractors License Lew(Chapter 9(commencing with Section]000)of Divlslen 3 of the
Buslnees end Professions Code)or that he a exempt therefrom and me basis for the alleged ASPHALT SHINGLES���
exemption.Airy ybla4on of Section 7031.5 by any applicant for a p umlf subjects the applicant to
e cHI penalty aline t m I u ail
- ❑I,eeownoftmJ a WOOD SHAKES ❑
the work,and the strut m is m r -
soreCode:The Como- cbret o r r WOOD SHINGLES ❑
Impromsmar n,arMw ogee o. t
each improamenin ere nal d offer for ase.If,however,
he
bulltling or improvemem
ie sold widen one year elm ibn, r he did OTHER(SPECIFY) SIS
M=drill or improre for Wr of
the roject(w5ea7004,Brusi n o nee not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of p e who ouilasorim Toms themon,eritl who rnn tsf rWects
wunaconvectorts)II Pqu a 'a PROVIDE MFGR.INSTALL.ATIONSPECS.
❑ o Owner
exempt u
WORKER'S COMPENSATION DECIARATIONAPPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under Penalty of perjury me of the following deciaretlon: - —,
C]I ham iwill maintain a Cerlllcefe d Consent to sell-Insure for workers Compensalbn, wo Building n / —
asprovkfadfor bySection 37W of the Lebon Code,for the padormarme of the weak for which thisI , � Q
permit k Issued. k/y 7 7 u
❑I their and will maintain Workers Compensation lreuraent,as required by Section 37W d / Seismic
the Lebon Code,for the performance of Ne work for which Nle permit U Issued.My Workers Total
Compensation Iroure r `�mlar antl Policy number ere: ry
Carrier J101/00l' /� TA/tf CO.Policy No. �8 p T0 Q---Z PERMIT AUTHORIZATION, DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
1. COMPENSATION INSURANCE INC,
❑ �l
(This section need not be completed fl the permit Is for one hundred dollars($1(0)or less.) /]
I certify that in he performance of me work for which this permit Is same,I shall not employ C—2— V
any person In any manner so as to become subject to the Workeri Compensation I-orms of C �– All roofs shall be inspected prior to any roofing material being
forma. p p / in3TaHed. If a roof is installed without first obtaining an
Date...�_!�_) Appkem –+ inspection,l agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It.after making this Cemn ioata w Exemption,year sfwutd babarma Applicant understands and will comply with all non point
subject to the Workers'Cmpensation prmislons of the Labor Code,you most forthwith compy pP P Y p
with such provisions o this Permit shall be deemed revoked. source regulations.
I call Nat I have read Ih6 application and state that me above Information Is correct-I agree
to comply with all city anci county ordinumcers and state lam rolalmi;to building construction,and All roof coverings to be class;. or better.
hereby authorize repreeenlatlms of this dry to enter upon the above-mentioned property for In-
spacdon purposes.
(We)agree to save,Indemnify antl keep harmless the City of Cupertino against Imbillma,
judgments,Forst.and expenses which may In any way accrue against said City in consequenceRE OF APPLICANT DATE
of tie gmnhng of thle permit
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: christya
Sec: Tp: Rng: Sub: Blk: Lot:37538046.00
INVOICE DATE.. . . . . : 09/29/1999
REFERENCE ID N . ..: 99090186
SITE ADDRESS . . ...: 907 S TANT AD AV
SUBDIVISION . ......
CITY ........ .....: CUPERTINO
IMPACT AREA . . .....
OWNER ...... . .....: MC KELVEY EARL C AND RUTH A
ADDRESS .... . .....:
i CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4601
CONTRACTOR . ......: LIC #
COMPANY . . . .......:
ADDRESS . . ........ :
CITY/STATE/ZIP ... .
TELEPHONE ........ :
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
PEERMF EE P 217.00 0.00 217.00
BSEISMICRE P 1.60 0.00 1.60
--------- ------------ -----------
218.60 0.00 218.60
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 # 1
Sec: Twp: Rng: Sub: Blk: Lot:37539046.00
DATE ISSUED....... : 09/29/1999
RECEIPT q....... . . : 10195
REFERENCE ID # ... : 99090106
SITE ADDRESS ..... : 907 S TANTAU AV
SUBDIVISION ...... .
CITY CUPERTINO
IMPACT AREA .......
OWNER MC IMLVEY EARL C AND RUTH A
ADDRESS . . . ........
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4601
RECEIVED FROM .... : TIM
CONTRACTOR ....... : LIC N
COMPANY .......... :
ADDRESS .......... :
CITY/STATE/ZIP ....
TELEPHONE ........:
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 16,000.00 217.00 0.00 217.00 0.00
M ICRE VALUATION 16,000.00 1.60 ------0.00 1.60 ------0-00
PERMIT : 218.60 0.00 218.60 ' 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ -"'--------------
CHECK 210.60 2690
------------
TOTAL RECEIPT 218.60
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
1'