991000220
•
- PERMIT
APPLICATION FOR CITY of cuPEHTINo NUMBER IAM
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)]]%-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRES /��J/�'��� /�(Y!1 I�//��1 n Q ��\ �am
1
RESIDENTIAL COMMERCIAL OTHER
OWNER'SHAZARDOUS
FIRE AREA
/
NNI P
YES ❑ If yes — I understand that a Class A
NAME
v
roof as Mbty is required.
ElInitial I.C.B.O. p
EXISTING C VERING
NUMBER OF EXISTING C@YERING
TO BE REMOVED TO BE RETAINED
PHONE.
CONTRACTORS
NAME
ADDRESS
TYPE F ROOF
C TY 8 ZIP t
X
BUILT-UP ROOF /�/��/
(/_
PH�+t
NUMBER
ASPHALT SHINGLES �9
WOOD SHAKES
L�CENSE15
Hereby ne TORS DECLARATION
that em licensed under of Chapter 9 (commencing calif Section
sion liessoons
]000) 0l Dlvldon 3 0l lh�usinass and Prolesslana entl license W In lull force and
effect. L
WOOD SHINGLES
Lkerme Claes Lk. Nu
�❑ � n
M II 11I
VAI1
OTHER (SPECIFY) ❑
Data contto1999
ER BUI N
ROPOSED OCT
hereby enhm thel am exempt fromContractors Ure reason.
Na e: Any cr's Uranus Law for the requires
(Sac. 7031 .5, Bullnose and Professions Code: Any city or county which requires a permit to
construct, alter, Improve, d prior to Its Issuance. also requiresthe
BUILT-UP ROOF ❑
file asiorrepairenystructure,
le licensed pursuant m ins pry
em that pursuant
for such permit to Ills aChapt
of the Centre
ofapplicant06 Co Ucrose Law (Chaplet
r 9 (commencing with Sedan ]000) of Division 3 0l the
of Ill
By
Pre
hisw
Badness and Professions ions Cede) or 0311 he is exempt therefrom and tits beefs for the alleged
ASPHALT SHINGLES _----- —
one 7031.5 q'arty epplfmnr foraIserMleWjeete the aplYlcant to
adyllpenity
of
e dull gaudy of rql more Nen live huMred dollen
anI"hurfor
the
WOOD SHAKES ❑
D1, es owner of Property. xmyemploll with wages as her sok comperal wu do
he work, d th
ane structure Is not Intended or offered for able (Sec. 704, Business and Prelee-
slons Code: The Cora actors License Law tlaea not appy to an owner of property who Wiles or
WOOD SHINGLES ❑
Improves thereon, and who does such work himself or through his own employees, provided that
f
such Improvements are not Intended or offered for sale. If, however, rhe Whiling or Improvement
Is said within one year of completion, the ownor-Wilder will have rhe burden of proving that he did
OTHER (SPECIFY)
not build or Improve for purpose of sale.).
❑I, as Ameroftheproperty, emexclusKOyc nuadingWffilicensedmntmcrorstoconstruct
Me project (Sec. 7044, Business and Profession, Code: The Contractor's License Law does not
—
PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Impenes thereon, entl wino conVack for such projects
with a conbectons) licensed pursuant to the Contractor's License law.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am sumer urNar Sec. ,B 8 P. C. for this reason
Owner Data
APPLI ATIO DATE
VALUATION
PERMIT FEE
WORKER'S COMPENSATION DECLARATION
///���...
�
...///'��y
r /
BuildingI U
hereby affirm under fain a of perjury one nen following tlederetWo:
have and will maintain a of the
r Consent to self -Insure for Workers Compenoatthis
as provltletl for by Section 3]000/ the Labor Cotlo, for the performance of the work for which this
perms Issued.
L
I ve end will maintain Workerb Compensation Insurance, as re turetl by Section 37DD of
I I
Seismic
e Code, for me performance of the k for which fl Aa permit Is Imued. My Workers
Total li
compemmil I nuc ca+der. Polley ra r ere: /],f /���
�(�
Gains r Potlry lq- L � �iL'�--
PERMIT AUTHORIZATION
DATE
CERTIFICATE EXEMPTION FROM WORKERS'
Q
COMPENSATION INSURANCE N.00
(This section read not be completed it the pormil is for one hundred dollars (51 00) or lees.)
cortlty ih In rhe pa armence of the work for which this permit la esu dull not eme
All roofs shall be inspected prior to any roofing material being
any person In by man m webecome a No t e warkabs Compe ficin Laws of
rotnib.
stalled. If a roof is installed without first obtaining an
Date A�pucanr
nspection, I agree to remove all new mat for inspection.
NOTICE APPUC T: II, ens mak dicate of Exemptim, you shaitl becoma
subject to the Workers' pensatbn proWskrm of the Letter Code, you must lorthydn compy
Applicant understands and will Co I wit all non point
PP Y
with such pro,dM me or MIs permit shall be Beamed revoketl.
sour g ations.
I Canty that l hat a read this application and date that the above information is corracL l apre6
m recopy with all dy and county emlrranrea and stele Iowa relating to Wilding construction, and -
roof COV rl ngt class "C" r batt
hereby authorize representations of this by to enter upon the abo -nh ntbn id property far In-
/W�
kA
spectkn purposes.
(We) agree to save, indemnity aM keep harmless fire City of Cupertino against liabilities,
I
k, �
Judgments, costa and expenses which may In any way acorea against sad City In consequence
of the grentkrg of fire 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
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
•
BUILDING PERMIT INVOICE OPERATOR: kurenb
Ser. Tp: Rng: Sub: Blk: LOC:35701049.00
INVOICE DATE......: 10/06/1999
REFERENCE ID 4 ...: 99100022
SITE ADDRESS .....: 22409 CANICE AV
SUBDIVISION .......
CITY .............. CUPERTINO
IMPACT AREA .......
OWNER ............. BY
ADDRESS ...........
CITY/STATE/ZIP ...: WEBSTER TK, CA 77598 -
El
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
---------------------
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
El
CITY OF CUPERTINO
�m 1 of 1 BUILDING PERMIT RECEIPT OPERATOR: karenb
COPY N 1
Sec: Twp: Rng: Sub: Blk: Lot:35701049.00
DATE ISSUED.......: 10/06/1999
RECEIPT q.........: 10250
REFERENCE ID # ...: 99100022
SITE ADDRESS .....: 22409 JANICE AV
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: UY
ADDRESS ..........:
CITY/STATE/ZIP ...: WEBSTER TK, CA 77598 -
TOTAL RECEIPT 178.20
VOICE ID DESCRIPTION
305 FRAME
601 ROOF TEAR OFF
603 ROOF BATTENS
0
VOICE ID DESCRIPTION
307 INSULATION
602 ROOF PLYWOOD NAIL
604 ROOF IN-PRDGRESS
RECEIVED FROM ....:
TIM
CONTRACTOR .......:
KAHN, RUSSELL LIC
# 17999
COMPANY ..........:
CROWN ROOFING INC
ADDRESS ..........:
214 CRISTICH LN
CITY/STATE/ZIP ...:
CAMPBELL, CA 95008
TELEPHONE ........:
(408)369-]444
FEE ID
UNIT QUANTITY
AMOUNT PD -TO -DT
THIS REC
NEW BAL
----------
BPERMFEE
---------.--------------
VALUATION 12,000.00
---------- ----------
177.00 0.00
----------
177.00
----------
0.00
ISMICRE
VALUATION 12,000.00
1.20 0.00
1.20
0.00
.L PERMIT
178.20 0.00
170
20
0.00
METHOD OF
PAYMENT AMOUNT
NUMBER
-----------------
CHECK
------------
178.20
------------------
41036
TOTAL RECEIPT 178.20
VOICE ID DESCRIPTION
305 FRAME
601 ROOF TEAR OFF
603 ROOF BATTENS
0
VOICE ID DESCRIPTION
307 INSULATION
602 ROOF PLYWOOD NAIL
604 ROOF IN-PRDGRESS