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99090033 3 (o;2 - PERMIT eApPLICATION FOR CITY OF CUPERTINO NUMBER . INSPECTION DIVISION - PERMIT EXPIRATION REROOF PERMIT (408)777-3228 - PERMIT EXPIRES IF NORM IS NOT STARTED ' WITHIN 180 DAYS OF PERMIT ISSUANCE OR WI DAYS FROM LAST CALLED INSPECTION. BUILDING`AA`/DDRESS - .3 - _ RESIDENTIAL COMMERCIAL OTHER OWNER'S HAZARDOUS FIRE AREA - h,,�� a� YES ❑ If yes—I understand that a Class A NAME D "`"A / root assembly Is required. NO ❑ Inu I.C.B.O.11 ADDRESS � � EXISTING ROOF COVERING PHONE 012S NUMBER OF EXISTING COVERINGS r CONTRACT 'S TO BE REMOVED TO BE RETAINED NAME— /� �e /7 ADDRESS //C� // n /1D G , TYPE OF R CITY 8 ZIP 7J I ' / p / EXISTING , PHONE iC) 4/ _11 -637 3 • BUILT-UP ROOF ' LICENSE ?-,7— , 0 NUMBER - ASPHALT SHINGLES / j .. DCENSED COMPACTORS DECLARATION I hereby affirm that I am lioenaed under provisions of Chapter 8(commencing with Section WOOD SHAKES 7000)of OWlsion 3 of the Business ara Professions Code,era my license is In lull face and 777 - effect. - 27 O'v: WOOD SHINGLES ❑ .'License Claes Llc.Number Dale— contract« OTHER(SPECIFY) ❑ . OWNER-BUILDER DECLARATI PROPOSED I hereby affirm that I em exempt from me Contractors Ucanse Law to, the bllowing real (Sec.7031.5,Buelroess anal Profession.Code: Any dty or county winch requires a permlt to construct,eller,Improve,demolish,or repair any structure,Prior to Its Issuenca,also mqulrs.the BUILT-UP ROOF ❑ applicant for such parmlt to file a signed statement that he Is licensed pursuant to the provisions - r of the Contractor's License Lew(Chapter 0(commencing with Section 7000)of DNlelon 3 of the �f Business,and!Prslesdons Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT$RING•ES-,, Ij9. 7 exemption.Any violation of Section 7031.5 by ars eppllunt for a permit subjects the eppllrant to /� �� I a col panels of not more then five hundred dollars w th wag.): WOOD SHAKES )1 /�1\ ❑I,k,and er the stnaure is ormryded or offered for gas Bgc.their 7AI,compensator,and,willdo ❑� the work,antl the etnxture is rqt Intended Law or offered for sale n ow er of BUWnty end Profen- dons esth Tele,contractorsawhstance Law doesnot apply toenowner ofpmpe s,who Win,or ❑ Improves snip mermen,end who does Sudo work heron or through his own employees,Improvement etl that WOOD$H NGt, S SEP Isco Impmvemame are not th offered for edea. ill however,the en of or Improvement I J q Iseoltlld or Improve for purcompletion,ofsthe awnerbulaar will neve me Women of prodrq that he dna OTHER(SPE I • 3 ^QO not build or Improve for Wrpose of eels.). E)I,as,owner of the property,em exclusively contreding with lioensed contractors to construct me project(Sec.7046,Business and Profeedons Code:The Contractors License taw does not PROVIDE I.C. :b! EPORT N0. apply to an owner of property weer buffets or Improves thereon,and who contracts for Basil projects, with a contractors)1lceneed pursuam to the contractors License Law, PROVIDE MFG R.INSTAL 1 am exempt under Sec. ,B&P.C.for this reason Owner Date APPLICATION DATE VALUATION PERMIT FEE WORKER'S COMPENSATION DECLARATION hereby affirm under maintain a of perjury one of the following"Iflg decefor Wn: �S. �s ,"-v ❑ have ora will mdnt37 I ofCanIfficatethe Lab of Consent to eperfor a for Worker's Compensation,ion, p p Building l� as pro is I for by Section 3700 of me Labor Coda,br the performance of cite work for which IMe 1e 16°11°°' Seismic Lthese =will maintain Workers f Use wovatan which this pe required tt d.My 3700rs / ItN Labor Cade,for the performance,of the wwk br whim This permit Is issued.My Workers �� '� Compensation Insure corder ara��Wli,ryuunumb11er are: S• qQ' Total I2{ .L^ Carriers ,��PaIIry No. 5 -)/-)/ _/r/�1�� - PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE NcC (This auction need not ba completed H the permit Is for one hundred dollars($10()or lee..) I cortlry that In the performance of the work for which this permit is Issued,I shell net employ _ any person m minnlr eo as Is beconoe euq t to wakam'Compo lu l Lawn of call- All roofs shall be inspected prior to any roofing material being fossa. installed. If a roof is installed without first obtaining an. Data � Applicant – inspection,I agree to remove all new materials for inspection. NOTIC TOA PLI :ANT: If,after making this Cen1ficat of Exemption,you should become Applicant understands and will comply with all non int subject l0 the Workers'Compenuatlon provisions of me Labor Code,you must brthwith comps- PP P y PO with such provisions or this pemnit shall be deemed revoked. source regulations. I cattily mat I have read min application and stele that the aboye Informa lion Is correct.I agree to herebyswaeall city zerepese county of the city antlstate teruon relating tobudding conetrudbn,aM All roof co�(en I or better. herebyauthorizepurpose representatives of this dry to enter upon me above-men8oned property for In- f/�`/,/ / specte) purpose. (We)agree to save,Iraemnlry and keep harmless the Cry of Cupertino epelnnt IleblAtlea, 7udgmenb,costs and expenses which Trey In any way accrue against said City n consequence SIGNATURE OF PPLICANT DATE t al the grentlng of this palter. 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 `:.'VOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE CITY OF CUPERTINO • BUILDING PERMIT INVOICE OPERATOR: karenb Sec: Twp: Rng: Sub: Blk: LOC:36208016.00 INVOICE DATE.. .. .. : 09/03/1999 REFERENCE ID # ...: 99090033 SITE ADDRESS . . . .. : 1143 ELMSFORD DR SUBDIVISION . . . . . .. CITY ...... . . . . . . . : CUPERTINO IMPACT AREA . . . . .. . OWNER ......... . . . . REKITTKE DAVID E ADDRESS ....... . . . : CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4901 CONTRACTOR .. . . . . .: COSMOS, RICHARD LIC H 18844 COMPANY .... .. . . ..: COSMOS ROOFING ADDRESS ... . . . . . . .: 450 SAN ANTONIO RD CITY/STATE/ZIP .. .: PALO ALTO. CA 94306 TELEPHONE . . . . ....: (415)493-63]3 FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE --------------- --- --------- ------------ ----------- BPERMFEE P 177.00 0.00 177.00 BSEISMICRE P 1.20 0.00 1.20 --------- ------------ ----------- 178.20 0.00 178.20 ID DESCRIPTION VOICE ID DESCRIPTION ........ ............................ ........ ............................ 305 FRAME 307 INSULATION 601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 603 ROOF BATTENS 604 ROOF IN-PROGRESS • CITY OF CUPERTINO Item 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: karenb COPY N 1 Sec: Twp: Rng: Sub: Blk: Lot:36208016.00 DATE ISSUED....... : 09/03/1999 RECEIPT 4. ........ : 9984 REFERENCE ID W ... i 99090033 SITE ADDRESS ..... : 1143 ELMSFORD DR SUBDIVISION ...... . CITY .. . .......... : CUPERTINO IMPACT AREA ...... . OWNER . . . ........ . : REKITTKE DAVID E ADDRESS . . ........ : CITY/STATE/ZIP ... : CUPERTINO CA, CA 95014-4901 RECEIVED FROM .... : TIM CONTRACTOR ...... . : COSMOS, RICHARD LIC # 18844 COMPANY . ........ . : COSMOS ROOFING ADDRESS . ...... . . . . 450 SAN ANTONIO RD CITY/STATE/ZIP . . . : PALO ALTO, CA 94306 TELEPHONE ....... . : (415)493-6373 FEE ID UNIT QUANTITY AMOUNT PD-TV-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- BPERMFEE VALUATION 12,000.00 177.00 0.00 177.00 0.00 BICRE VALUATION 12,000.00 1.20 0.00 1.20 0.00 T PERMIT 178.20 0.00 178 20 0 00 METHOD OF PAYMENT AMOUNT NUMBER ----------------- ------------ ------------------ . CHECK 178.20 10206 ------------ TOTAL RECEIPT 178.20 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 •