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99120090 X19/aoo qa 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 180 DAYS FROM LAST CALLED INSPECTION. • BUILDING ADDRESS - '/ , RESIDENTIAL v COMMERCIAL-OTHER OWNER'S/� ,�/ ' / HAZARDOUS FIRE AREA NAME_/moi�/ lS �//�/y YES ❑ 11 yes'I rstand tired a Class A / p NO ❑ == required.lnftW I.C.B.O. ADDRESS-IDS 91 {/l S.�a� DfLI EXISTING ROOF COVERING PHONE� NUMBER OF EXISTING COVERINGS CONTRACTOR' - / r NAME��S7_ZOA/G TN -ra 11.4 A....,�� I✓ TO BE REMOVED TO BE RETAINED CITY B Z P777�A e i tT• s, C, a.? TYPE OF ROOF COVERING —7 EXIsnrIG. PHONE y/T' I7 / (/ Z 3Py BUILT-UP ROOF LICENSE e NUMBER ASPHALTSHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under provisions of Chapter a(commencing with Section WOOD SHAKES 7000)of Division 3 of the Buelnes i and Professions Cade,and my license Is In lull force and effect. _ WOOD SHINGLES Lkenee Close Lk.Number Date � � ContraIXor OTHER(SPECIFY) OWNER-BUILDERDECLA RAT N PROPOSED I hereby affirm that I am exempt Imm the Contracto s License Lew for the Viewing reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires e permit to construct,after,Improve,demollsh,or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF applicant for such permit to file a signed tffiu ant that he Is Ilcamed Wrsuenl to the provisions of Me Contractor's License Lew(Chapter B(commencing with Section]000)of Dlvlslon 3 of Me .Business and Professions Code)or that he a exempt therefrom and Me basis for the afleged ASPHALT SHINGLES ❑ • exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a dull penalh of not more Men INa hu gifted dollars($500).): ❑ C]1.as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES tfre work,entl the structure Is not immtled or offered for We(Sec.7044,Business aM Prelee- eions Codo:The Contractor's License law don not apply to an owner of property who outfitter int roves thereon,end who does such work himself or through owne WOOD SHINGLES P g building s,provided Met ❑ such Improvementsnoneyears not of completion, or offered loc sale.If,havethe burden en of r of improvement iewild ctid ornprovemr purpose sa[eowner-Wiltlerwill have Me Wrden of proving Mel he did OTHER (SPECIFY) not build or Improve for purpose of sale.). D 1,as owner of the property,am exduslvely contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:The Contractor's Lbenw Law does not PROVIDE I.C.B.O. REPORT NO. apply to an owner of property who bulbs or Imieri thereon,and who contrails for such projects with a conn ctor(s)licensed pursuant o Me Contractor's Ucense Law. PROVIDE MFGR.INSTALLATION SPECS. 01 am exempt under Sec. ,B&P.C.for thio own owmer Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECD TION I hereby affirm under penalty of Perjury one of the Idlowg daclaratlon: ❑1 have and will maintain a Cenigcate of Consent to sell-Insure for worker's Compensation, Building peprovbwfor by Section 3700 o1 Me Lobar Code,for Me performance of Me work for which Mls 9 ��2 permit lave amr! /G Seismic F7 I have end will the pelrf Worker's f ffies er Insurance,as required by Section 3700rs / To Labor Code,for the performance of the number for which this permit b Issues.kdY Worker's p Q Compensation Insurance ce tier eM Policy number era: �J Total Carrier �TT `!Y� ;5411 Policy No. Q PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.CQ (This section need not be completed i1 the Permit fs for one hundred Calors($100)or less.) . any p ea thin any mmaarperformance er was to obeclomwork se bract which ffiew rrlpermit ichi'bCompanwl0on Laws employ GOP All roots shall be inspected prior to arty roofing material being forms, ' stalled. If a roof is installed without first obtaining an Date 4e,t - P9 Applicant inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: If,after maks is Ce dicate of Exemption,you shout barom Applicant understands and will comply with all non point subject to Me Workers'Compensation prorisione of the Labor Code,you must IorMwith comply with such provisions or MIs Permit shall be doomed revoi source regulations. I certify that I have reed thin application and state that the above Information Is correct I agree to comply with all city and county ordinances and state laws relating to bulking wrthtr cten,and All roof coverings to be class" " r better. hereby authorize representatives of this my to enter upon the above-mentioned property for In. epepurpose!. Weft (We)agree to a d t Indsmnih end keep harmless nyythe City of sued Ci y In col Ii quer obhe gran rolls entl a Permit. which may In any way a¢rue egelnat aaltl City In wnsequenc NATURE OF APPLICANT DATE of the granting of this permll. ' 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE CITY OF CUPERTINO BUILDING PERMIT INVOICE OPERATOR: nancyc Sec: Twp: Rug: Sub: Elk; Lot:31625023.00 ' INVOICE DATE. .. . . . : 12/15/1999 REFERENCE ID N . . . : 99120090 SITE ADDRESS .. . ..: 10191 VISTA DR SUBDIVISION . . . .. .. CITY . . ... . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . . OWNER . . ....... . . . : ALLEN PATRICK R AND CHARLENE F ADDRESS ........ . . : CITY/STATE/ZIP .. .: CUPERTINO CA, 95014-2212 CONTRACTOR .... . . . : LIC 4 COMPANY . ....... . . : ADDRESS . ....... . . : CITY/STATE/ZIP . . . , TELEPHONE ..... . . . : FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DOE --------------- --- --------- ------------ ----------- BPERMFEE P 209.00 0.00 209.00 BSEISMICRE P 1.50 0.00 1.50 BUSLIC P 90.00 0.00 90.00 --------- ------------ ----------- 298.50 0.00 298.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION .. ............................ ..--- ---------- ................ 5 FRAME 307 INSULATION 601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 603 ROOF BATTENS 604 ROOF IN-PROGRESS CITY OF CUPERTINO 0m 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: nencyc COPY # 1 Sec: Tp: Rng: Sub: Blk: Lot:31625023.00 ' DATE ISSUED.......: 12/15/1999 RECEIPT #.........: 10928 REFERENCE ID # ...: 99120090 SITE ADDRESS .....: 10191 VISTA OR SUBDIVISION ....... CITY .............: CUPERTINO IMPACT AREA .... ... OWNER ............: ALLEN PATRICK R AND CHARLENE F ADDRESS ..........: CITY/STATE/ZIP ...: CUPERTINO CA, 95014-2212 RECEIVED FROM .... : TIM CONTRACTOR... .. ... : LIC # COMPANY ..... .....: ADDRESS ...... ..., : . CITY/STATE/ZIP .... , TELEPHONE .... .... : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS AEC NEW BAL ---------- ------------- ---------- ---------- ----- _____ ____------ BPERMFEE VALUATION 15,000.00 207,00 0.00 207.00 0.00 BSEISMICRE VALUATION 15,000.00 1.50 0.00 1.50 0.00 10LIC FLAT RATE 1.00 90.00 0.00 90.00 0-00 TAL PERMIT 298.50 0.00 298.50 0.00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ ---- ___- CHECK 298.50 2426 ' ............ TOTAL RECEIPT 298.50 VOICE ID DESCRIPTION VOICE IO DESCRIPTION ........ ..........:................. ......... ............................ 305 FRAME 307 INSULATION 601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 603 ROOF BATTENS 604 ROOF IN-PROGRESS •