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99090002 'i q O 0112 PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBER R FEXPIRATION REROOF PERMIT INSPECTION DIVISION PE(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WRHIN 100 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADD-DRESS Sl6 J.4,117-B/1• Ci D D/C . RESIDENTIAL COMMERCIAL OTHER .OWNER'S HAZARDOUS FIRE AREA 1190 D y f. YES ❑ If yes-I understand that a Class A NAME /Z Z 4f Z ✓ T roof assembly Is required. NO trlifial I.C.B.O.A ADDRESS- P)l EXISTING ROOF COVERING - PHONE ' yop 9 to NUMBER OF EXISTING COVERINGS CONTRACTOR'S NAME FZ 7ti L r D QU/f� -2 q it 2 TO BE REMOVED TO BE RETAINED ADDRESSZ/ !tib f�//�,G ).D ti qv, �f' ZDS TYPE OF ROOF COVERING CITY 8 ZIP EXISTING PHONE �yD�J 7YG '207r BUILT-UP ROOF LICENSE NUMBER 3?rf?T - ASPHALT SHINGLES LICENSED CONTRACTORS DECLARATION I hereby affirm III I em Ycerued under provisions of Chapter 9(commencing with Saction WOOD SHAKES 7000)of Division 3 of the Business and Professions Code,and my license is in lull force and effect. License Class �' ?9 Uc.Number 37 f�? y WOOD SHINGLES Data `9'l `�9 Centrad« a-lror7v R/1oF/2L' OTHER (SPECIFY) OWNER-BUILDER DECLARATION Is PROPOSED I hereby affirm that I am exempt from the Contmctora Lifierae Law for the as following reon. (Sec.7031.5,Business and Professlons Code: Any city or county which requires a permit to construct eller,Improae,tlemoIIS,.or repair any structure,prior to its Issuance,also requires the BUILT-UP ROOF ❑ applicant for such permit to file a signed statement that he is licensed pursuant to the irmAsbns of the Contractors License Law(Chapter 9(commencing wlth Section]000)of DWlsmn 3 of the Business and Promsaiora Cotle)or that he Is exempt Ihartifmn and the basis for the alleged ASPHALT SHINGLES exemption.Any vlobnon of Section 7031.5 by arty awkStr t for a permit subjects the applicant to a CMI perrelty of not mare then five hundred dollars($501 ❑1,as owner of the property,or my employees with wages as their Sole mmperaatlon,all do WOOD SHAKES .❑ the work,and the structure is not informed or offered for sale(Sec.7040,Business end Profes- sionsCode: The Contractors Uceraa Law does not appy to an owner of property who builds or WOOD SHINGLES El moral and who does such worn himself or through his own employeas,proyided that such improvements are not amended or offeratl for sale.If,however,the Wilding or improvement Is all withn one year of completion,me owror-Wilder will have lire burdon of proving that he did OTHER (SPECIFY) ❑ nat buid w Improve for purpose of sale.). ❑I,as owner of the property,am exdusivey contacting with llcaral contractors to construct the project(Sec.7044,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O. REPORT NO. appy to an owner of property who builds«Improves thereon,and who contracts for such projects wuh a contractors)Imenead pursuant to the Contractors lxense Law. PROVIDE MFGR. INSTALLATION SPECS. ❑I am exempt under Sec. ,B&P.C.for this reason Owner CI r( 4;;4 T .y(& 2 Data 9- WORKERSCOMPENSATIONDECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm under penalty of perjury one of the following declaatlon: 11 have end will maintain a Certificate of Consent to self-insure for Workers Compensation, Building as provided for by Section 3700 of Ne Labor Code,for the performance of the work for will this per mil is issued' / G+ l/➢- �/ Seismic ❑I hexa end mp will maintain Workers CoInsurance,tion Insurance,as required by Section 3700 0l � f the labor Code,for the performance of the work for which Its permit Is Issued.My Workers / w Compensation Insurance ca for and Po lcy number are: Total iZLLL ' Carrier -V- 7-970F A- rr d Polipy Na. Z.r.s-oD dl/Sl PERMIT AUTHORIZATION DATE CERRFICATEOF EXEMPTION FROMWORKERS' - COMPENSATION INSURANCE N.CQ (This section need not be completed If the permit is for one hundred dollars($10)or leas.) r- I certHy that In the performance of the work for which this permit Is Issued,I shall not employ any person In any manner co as to bec«ne subject to the Workers'Compensation Laws of Call-' All roofs shall be Inspected prior to any roofing material being fornla. installed. If a roof is installed without first obtaining an Dale Applicant Inspection,I agree.to remove all new materials for inspection. NOTICE TO APPUCAM: If,after making this Certlllcam of Exemption,you should become q hcant understands and will coon with all non subject to the Workers'Compensation pravlsbns of the Labor Code,you must forthwith comply PP comply Point with such provisions or this permit shall W deemed revokal source,regulations. I certly that I hove read this application and state that the shove Information Is correct.I agree to campy,with all city and county,crdnences and state laws matng to Wilding construction,and! All roof Coverings to be class"C"or better. hereby authorfze repres rnwtNee of this city to enter upon the abovw menfioned property for Ion spacbon purposes. p, (We)agree to save,indemnity and keep harmless the Cry of Cupertlno against liabilities, - L 7 Judgments,costs and expenses which may In eny,way accrue against mid City In consequence of the granting of this permk. SIGNATURE OF APPLICANT DATE PRE-INSPECTION: PLYWOOD: IN-PROGRESS: INSP. DATE INSP. DATE - INSP. DATE TEAR OFF INSPECTION: BATTENS: FINAL: INSP. DATE INSP. DATE It DATE NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION OFFICE COPY CITY OF CUPERTINO Item 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: christya COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: DATE ISSUED. ......: 09/01/1999 RECEIPT p. . . . .....: 9950 REFERENCE ID M ...: 99090002 SITE ADDRESS ..... : 7518 WATERFORD SUBDIVISION ....... CITY ... . . . .......: CUPERTINO IMPACT AREA ...... . OWNER . ........... : RZESZUT, JOYCE ADDRESS .......... : CITY/STATE/ZIP ... : CUPERTINO, CA 95014 RECEIVED FROM .... : CHUCK CONTRACTOR ....... : GONZALEZ, FRANCISCO LIC k 19450 COMPANY .......... : GROMO ROOFING COMPANY ADDRESS .......... : 121 W WASHINGTON AVE CITY/STATE/ZIP ... : SUNNYVALE, CA 94086 TELEPHONE ........ : (408)746-2075 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL BPERMFEE VALUATION 7,000 00 127.00 0.00 127.00 0.00 BSEISMICRE VALUATION 7,000.00 0.70 0.00 0.70 0.00 TOTAL PERMIT 127.70 0.00 127.70 0.00 Mo OF PAYMENT AMOUNT NUMBER _______ ________ ____________ __________________ OTHER 127.70 VISA ------------ TOTAL RECEIPT 127.70 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 •