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99070053 CD 3 0 q�D C7 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 `/+ /� out US Ap�v�j_ RESIDENTIAL COMMERCIAL OTHER OWNER'S `` - - HAZARDOUS FIRE AREA NAME �C f'k0 HF,LM�I`� ` VES ❑ Ifyes— Ubtyi island Ulata Class roof assembly hand that NO ❑ Initial I.C.B.O.a ADDRESS 2'\$, I -QOGLUMgU� AUS- - EXISTING ROOF COVERING PHONE NUMBER OF EXISTING COVERINGS I COMRA /�O.�R,�'S ` NAME Ffs'�`+�AraGC. h.QS FtN Cr l.o.. TO BE REMOVED \I/. ADDRESS,. TYPE OF ROOF COVERING CITY&ZIP •-2°tZ- L,�Nc-o t,nl Aver, - . EXIS11NG PHONEBUILT-UP ROOF ❑ CENSE NUMBER ASPHALT SHINGLES ❑ LICENSED CONTRACTORS DECLARATION I hereby affirm that I em licensed under provisions of Chapter B(commencing with SectionWOOD SHAKES ® ' 7000)of DMalon 3 or ga Business and Professions Coca,and my license Is In lull force and affect. WOOD SHINGLES . � o Ucanee Class C--!A Lb.Numberp Data �- Z� `�ry Contreaor&*N ntSSny3Gr_ ggjf `jk Ce ' OTHER(SPECIFY) I, OWNER-BUILDER DECLARATION PROPOSED (J I hereby affirm that I em exempt from the Contractor's License Lew for the following recraw.. JUL b q e D (Sec.7031.5,Buelmas and Professions Code: Any city or ceunty which requires a Permit to Il 1999 construct,alter,lmprove,demolish,orrepair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF ❑ applicant for such permit to fib m a signed statement that he Is licensed Wreuent to the provisions of the Contractors License Lew(Chapter B(comntenci g with Section 7000)of Creech 3 of mrs ,.rA, Business and Proleeelons Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGIrEB;r Elwempilon.Any violation of Section 7031.5 by any sppllcent for a permit subjects Me applicant to e cMl penalty of not more than five hundred dollars($500).): ❑I,as owrwr of the property,or my employees with wages as mer We compeneetlon,will do WOOD SHAKES A the work,and the structure Is not Intended or offered for sale(Sec.7044,Business ark Proles- BionsCode:The Contractors License Law does not apply to an owner of property who bade or WOOD SHINGLES El thereon,and who dose such work hirtself or through ha own employees, adat - such Improvements are not Intended or offered for sale.IL however,the bullcmg on Improvement Is sold within one year of completion,the oxner-builder will have the burden of proving that he did OTHER(SPECIFY) ❑ not bold or Improve for Wrpose of fele.). ❑I,as owner of the property,em exdustvely contrecting with licensetl contractors to comatrucY - the project(Sec.7044,Business arrd Profession Code:The Contractors License Lew does rot PROVIDE I.C.B.O.REPORT NO. apply to an ovmer of property who bulks or Improves thereon,and who contracts for such projects with a contractors)licensed pursuant to the Contractors Licerae law. PROVIDE MFGR.INSTALLATION SPECS. 1 am exempt under Sec. ,B&P.C.for this reesan Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the Wlowing declaration: �y �h/Jf -11 have and will maintain a Certlficate of Consent to sclbinsure for Workers Compensation,. W BDi ding5lw 00 as provided for by Section 3700 of the Labor Code,for the performance of the work for which this r/��•--r�Q a I (�( .mss permit is asued. / / "I,ll "O seismic ` 101 haw and will maintain Workers Compensation Iraurence,as required by Section 3700 of , _Ihs Labor Code,for the performance of the work far which this penult le Issued.My Workers Compensation Insurance carrier ark Policy number are: Total (:�a 1 CernerAM6('%A l,j Pailw%00 "IS[cyNo. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.Co (This section need not be completed If the permit Is for one hundred dollars($1 W)or see.) I certify that In the performance of the work for which this permit Is Issued,I shall not employ any person In any manner so as to became subject to the workers'Compeneatbn Laws of Cell- All roof.^.shall be inspected prior to any roofing material being fornle. _ installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for Inspection. NOTICE TO APPLICANT: II,after making this Certificate of Exemption,you shaAd become Applicant understands and will subject to the Workers'Compeneadon provisions of he Labor Cade,you must forthwith compty PP comply P Y with all non Point with such provisions tor this permit shat es deemed revoked. - souf regulations. I ceruty het I have read this application and state that the above Informedon Is coned I agree to compty with all city and county ordinances and state laws roaung to Wilding constiucllon,arb Allr ling bed Or better. hereby auttwrlxe representa0vee of this city to enter upon he abovemeni oned property forIrylen In- all purposes. 7- (We)agree to save.Indemnity and keep harmless the City of Cupertino against Ilabllldn. / 7/--� judgments,coals and expenses which may In any way accrue against said City In owsequern of Me granung of this permit. SIGNATURE OF APPLICANT DATE 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 _ s ' CITY OF CUPERTINO I. 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: karenb COPY N 1 Sec: Trp: Rug: Sub: Elk: Lo[:35614030.00 DATE ISSUED.......: 07/27/1999 RECEIPT q... ......: 9631 REFERENCE ID k ...: 99070053 .. SITE ADDRESS .....: 21871 COLUMBUS AV SUBDIVISION ...... . CITY ............. : CUPERTINO . IMPACT AREA ....... .i OWNER .... ........: HEII14AN JOHN J AND FAUSTENE V '. ADDRESS .......... : CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4714 RECEIVED FROM .... : TIM CONTRACTOR ....... : DADDARIO, STEVE LIC N 20739 COMPANY .......... : RENAISSANCE ROOFING CO INC ADDRESS .......... : 2292 LINCOLN AVE CITY/STATE/ZIP .. .: SAN JOSE, CA 95125 a TELEPHONE ........ : (408)448-0697 FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW HAL _________ ________ _____ _____ BPERMFEE VALUATION 17,000.00 227.00 0.00 227.00 0.00 BICRE VALUATION 17,000.00 1.70 0.00 1.70 0.00 __________ __________ T PERMIT 228.70 0.00 228.70 0.00 METHOD OF PAYMENT AMOUNT NUMBER _________________ ____________ __________________ CHECK 228.70 15735 ------------ TOTAL RECEIPT 228.70 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 •