99090086 3 q 016100 TO
PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1B0 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS T.�I■/ //yy / '^�//
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
r YES ❑ It yes—I Understand that a Class A
NAME root assembly is required.
?
NO ❑ It" I.C.B:O.If
ADDRESS jl F+ �r q EXISTING ROOF COVERINQ
PHONE �. ^�� NUMBER OF EXISTING COVRINGS
CONT TOR'87—
TO BE REMOVED TO BE RETAINED
NAME
ADDRESS TYPE OF ROOF COVERING
CITY a zip EXISTING
PHONE BUILT-UP ROOFLICENSE
❑
NUMBER 1 ASPHALT SHINGLES
UCENS=NTPACTOFIS DECLARATION
7000)a gvalamlo tof hat l am licen CeM P oOasdanoe Cotle�arM m(Il�cemrremealelnglue b cantand een D S KES //`y'
enact.
WOO HIN ES ❑
Lamile Lk.Number -
OTHE
ICA
p/
Dere Q
OWNER-BUILDER
GUILDER DECLARATION PROPOSED I D
hereby affirm Bu test em exempt from Me Contractor's or ccuu Law is the browing reason.
(Sec.]0315,Bimprove and Profeeslone Ir any Any dry or county welch requires a quires to
construct,eller,Improve,damdiaa r re"Ir structure,prku to its 1pursuantalso requires the BU A 19991
of the
for such penult to Ills a slgnetl statement that g itI Sectio 70DO)of
the gra Of the
Business the Contractor's ssions Lew(Cheptar a is ex a ptng with Sectbn]000)of Division 3 0l the
examiI and violation of Code)or tiro.he U exempt therdra and the laces for the alleged ASPHALT SHINGLES ❑
a chit en.Any of not more
of Sectionire hull 5 by ercy appikon for a permit eublects the eppllrani to
e cknl penalty of not mare then Me hundred tldlare($5001 J:
C-]1,as owner at the property,or my ampayms with wages as their sole compensation,will do WOOD SqIARES
the wok,aria the structure is not Intended or offered for seen(Sec.70",Business and Proles-
veons Coca:The Contractors License Lew clues not appy to an owner of property who Wide or - WOOD SHINGLES
improves therein,and who clow such work himself or through his am employees,provided that ❑
such Improvements are not Intended or allered tar scree.If,however,the Wilding or improerment
Is add within one year of completion,the owmenWllder will neve ins Wrden of proving that he did OTHER(SPECIFY)
not bulb or Improve ler purpose of seen.).
]L as owner of the property,am exclusivelysions Cad :Ti elle Contractoicensed rs
Lloon er to constnat of
the project(Seer of
curtness and Professions Cotler The shot
L ctsfo Lew Coes not PROVIDE LC.B.O. REPORT NO.
appy to c ntownerof properly,who Wide orImproves thereon,antl who contracts for such projects
with a conve exempt
licensedrSe pursuant m me Caniredore License Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑I am evertpt antler Sec. ,B 8 P.C.for mis reason
Owner Date APPLI ATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECIARATION
I hereby allirm under Penalty of perjury,one of the following declaration: _^
R novo and will maintaln a of thel Lab of Consent to self-insure for Worker's Comp which this
/�1 iqq
�j � BUl dinges pr I hav lord Semon 37000)rho Leber Cada,tar the performance of me work brwhbh We V I vl
t is Issued. Seismic
have and will maintain Workers Compo tion Insurance,as required by Section 3700 of
LeWr Code,for me performance of the we for which this permit Is Issued.My Workers Tota
Comw.tl Ineu rice cirri Policy r era:
Carrier Policy N�_Igg _ PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,CQ
(This scratch need not be completed II the permit Is for me hundred dollars($100)or less.)
I certiryet Io the a' rmence al the work for wl this permit Is issued.I"I rot employ
any person arty m nner so es to Demme subject to the Workere Co hrensatbn Laws of Cell- All roots shall be inspected p 'or to any roofing material being
Iomla' I - installed. If a roof is installed without first obtaining an
oath Applicant inspection,I agree to remove all new materials for inspection.
Nonc TO'P[
P LICANTlf,after makeg this Certificate of Exemption,you shpdd become Applicant understands and will I with all non Dint
subject to the Workrs'eCoreperuamir proveekxts of the Labor Code,you meat lormwith comply PP comply y P
with such provisions or Mee permit shell be deemed revoked. source regulations.
I tartly that I have food this application and slate that fine above el meten is carred.I agree
to campy,with all dry and county,orNnances and state laws relating to building construction,antl All roof coverings to be class Or better.
hereby authorize representatives of this city to enter,upon the eDove-min0ortetl property W In-
spectbn purpea.oa // LJ
(We)agree to save.Incennity and keep harMesa Me Gry d Cupartlno ap Inst nabNltlesi 7 C
judgments,costs antl expenses whim may In any way acme against said Ctry In consequence ATE
of Me 0=ting of this permit. SIWATJRE P I
PRE INSPECTION: PLYWOOD: IN- R ESS:
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: karenb
Sec: Twp: Rng: Sub: Blk: Lot:35620013.00
'INVOICE DATE..... . : 09/14/1999
REFERENCE ID N . . . : 99090086
SITE ADDRESS . . . . . : 21543 TERRACE DR
SUBDIVISION . . . . . . .
CITY . . . ........ . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER . ........ . . . : MILLER AUSTIN L TR AND MARIAN
ADDRESS .... . . . . . .:
CITY/STATE/ZIP . ..: CUPERTINO CA, CA 95014-4741
CONTRACTOR . . . . . ..: KAHN, RUSSELL LIC $ 17999
COMPANY ..... . . ...: CROWN ROOFING INC
ADDRESS . . . . . . .... : 214 CRISTICH LN
CITY/STATE/ZIP ... : CAMPBELL, CA 95008
TELEPHONE . . ......: (408)369-7444
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPERMFEE P 247.00 0.00 247.00
BSEISMICRE P 1.90 0.00 1.90
_________ ____________ ___________
248.90 0.00 248.90
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
" o
CITY OF CUPERTINO
1 of 1 BUILDING PERMIT RECEIPT OPERATOR: karenb
COPY 4 1
Sec: Twp: Rug: Sub: Elk: Lot:35620013.00
DATE ISSUED... . . . . : 09/14/1999
RECEIPT 4.... . . . . . : 10071
REFERENCE ID 4 . . . : 99090086
SITE ADDRESS . . . . .: 21543 TERRACE DR
SUBDIVISION .. . . ...
CITY ......... . . ..: CUPERTINO
IMPACT AREA .. . . ...
OWNER ..... . . ... ..: MILLER AUSTIN L TR AND MARIAN
ADDRESS .. . . . .. ...:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4741
RECEIVED FROM .... : TIM
CONTRACTOR . . . .... : KAHN, RUSSELL LIC 4 17999
COMPANY . . . . . ..... : CROWN ROOFING INC
ADDRESS . . ... .....: 214 CRISTICH LN
CITY/STATE/ZIP ... : CAMPBELL, CA 95008
TELEPHONE (408)369-7444
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS RED NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 19,000.00 247.00 0.00 247.00 0.00
BMI CRE VALUATION 19,000.00 1.900.00 1.90 0.00
-
PERMIT 248.90 0.00 248.90 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
CHECK 248.90 2912
............
TOTAL RECEIPT 248.90
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