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99080017 / PRM APPLICATION FOR CITY OF CUPERTINO NMB INSPECTION DIVISION PERMIT EXPIRATION REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 190 DAYS OF PERMIT ISSUANCE OR f 190 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS CCC L�1 C401— D RESIDENTIAL v COMMERCIAL OTHER OWNER'S . AREA YES El iClassA NOnr/ V o=mlimred. . NO ❑ Initial I.C.B.O. ADDRESS 2-2 •U/LLJ*SILL C� Jg'V) !//,5 CvdTQC G4: EXISTING ROOF CWERING PHONET QS� O O NUMBER OF EXISTING COVERINGS NAME //%✓� c�Pli-SOJA�- tGF�(o- - TO BE REMOVED TO BE RETAIN ADDRESS �! TYP OF ROOF COVE CITYazIP�cSrr n. STr .S-S, (ia �tS//2 EXISTING PHONE � - 0P -78—03.30 BUILT-UP ROOF El ' NUMBER /6 8 ASPHALT SHINGLES UCENS d under TRACTORS of C LARATION Q hereby)ofD affirm that em ueness under provlelone 01 Chapter 9(comme Is with Section WOOD SHAKES 7000)of Division 3 0l the BUJlnew err0 Pmfeaelons Code,and my license b In NH lona eM al P GWOOD SHINGLES ❑ Ucense Class `-��� / Up.Number/y7�j0 8' . Date- '7�Z9"9 f' ConnectorpAye SP.e ea,..e Rt'`o OTHER (SPECIFY) ❑ OWNER-BUILDER DECLARATION PROPOSED I hereby affirm that I em exempt from the Contractors License Lew for the following reason. D (Sao.7031.5,Sutlnsw and Professions Code: Any dry or county which requires a permit to construct,after,Improve,denwlleh,or repair any structure,prior to Its Iwuarme,also requires the BUILT-UP ROOF ❑ applicant for such permit to file a dgned statement that he le licensed pursuer;to the provlel0no of the Contrectah Loomis,Lew(C ar g commandop with Sector 7000 of DNblon 3 of the QQ Buelneee and Professions Code)or that he Is exempt iherehom and Me basis for the alleged ASPHALT SHIN LAS AUG' JGki� 1999 exemption.Any vMatlon of Sectlan 7031.5 by any applicant for a permit subjects the applicant to V pn 1 e civil penalty of not more than five hundred callers($500).): 9 /� ❑I,as owner of the property,or my employees with wages as their ale compensation,will do WOOD SHAKE Me e ❑ J work,anti b me structure not Intended or offered a.for sale(S 7044,BmInss aand Proles- By sone Code:The Contractor°Lken"Lew does not appy to an Amar of property who builds or WOOD SHINGLE Improves MereOn,ark who does such work himself or through his own amp"", rovided that such Improvements are no;Interked or offered for safe.if,however,the Wilding or Pmprovement is sold Mill one year of competon,the owner-lwloer will hese the 0urden of proving Met he cd OTHER(SPECIFY) ❑ ' not Wild or Improve for purpose of sale.). ❑I,es,owmer of the property,em exclusively contractln wfM lkenwticanirectoro to construct the proles(Sec.7044,Business and ProlwJlons Code: he Contractors Ucensa Law does not PROVIDE I.C.B.O..REPORT NO. apply t0 an owner of property who Wilds or Improves thereon,and who contracts for such projects wIM a contrecions)Iicmmd pursuant to the Contremcre Lcerse Law. PROVIDE MFGR.INSTALLATION SPECS. C]I am exempt under Sea. B a P.C.for this ressm OwnerDate WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE I hereby affirm urker Penalty of perjury one of the following declereton: ❑I neve and will maintain a Certificate of Consent to self-Irsura for Workers Compensation, ©O Building as,provided for by Section 3700 of the Labor Code,for the performance of the worn for which this permit Is issued. �00 ❑I flava and will maMrofn Workers Compensator Insurance,as required by Section 3700 of Seismic the Labor Code,for the perWirance of the work for which MIS permit Is bailed.My Workers }}�� Compensation Insurance tamer entl Policy number a Total Canler Q$ i,&e JI lnAa� Pollcy.No. Qj 4 o 117 PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS'- - COMPENSATON INSURANCE N.C[] —� (This section need not be completed If the permit is for ane Wrkred cohere($100)or less.) I cortlfy Mat In Me performance of Me work for which Mie pxmlt Is Issued,I shall not employ any perem In any manner a as to became subject to the Workers'Compensation Laws of Call- All roofs shall be inspected prior to any roofing material being - for"I°' installed. If a roof is installed without first obtaining an Date Applicant inspection,I agree to remove all new materials for inspection. subNOTICE theNw�kere Comice"alon rrovsionls oofthe Labor prion,you should become Applicant understands and will comply with all non point p you must bmhwlM comply with such provisions or true permit shell be deemed revoked.' SOUfCB regulations. I col that l have reed 444 application and state that the above Information is cor act,l agree to comply Mid,of city ark county ordinances and State lease relating to building constructlon,and All roof cover is t e CIaS or better. hereby Purposes.ze repressnbllvee of Mie cry IO enter upon the ebave mentioned property for.lm �'� hereby purposes. (We)agree to save,Indemnity and keep harmless the CIry of Cupertino a Nmat Ilablldlas, jed menta,toes ad sxpensee wMch may In any way acorus against said City In conwqumce of iPie renting of Mie permt. SIGNATORE 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: karenb qw Sec: Twp: Rug: Sub: Elk: Lot:36944001.00 INVOICE DATE. . . . . . : 08/03/1999 REFERENCE ID # . . . : 99080017 SITE ADDRESS . . . . . . 20310 PACIFICA DR SUBDIVISION . . . . . . . CITY . . ...... . . . . . : CUPERTINO IMPACT AREA ... . . . . OWNER ........ . . . . : WONG JOHN C AND JUNE ADDRESS .... . . . . .. : CITY/STATE/ZIP . . .: BLUE BELL PA, CA 19422- CONTRACTOR ..... . . : LIC 4 COMPANY ....... . . .: ADDRESS ..... . . . . .. CITY/STATE/ZIP .... TELEPHONE . . . . . . . . : FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE --------------- --- --------- ------------ ----------- BPERMFEE P 107.00 0.00 107.00 BSEISMICRE P 0.50 0.00 0.50 --------- ------------ ----------- 107.50 0.00 107.50 VOICE ID DESCRIPTION VOICE ID DESCRIPTION p0p'5 FRAME 307 INSULATION 1 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 3 ROOF BATTENS 604 ROOF IN-PROGRESS • CITY OF CUPERTINO lt�. 2 of 4 BUILDING PERMIT RECEIPT OPERATOR: karenb COPY N 1 Sec: Twp: R g: Sub: Blk: Lot:36944001.00 DATE ISSUED....... : 08/03/1999 RECEIPT p. . . . ..... : 9715 REFERENCE ID N ...: 99080017 SITE ADDRESS . . ...: 20310 PACIFICA DR SUBDIVISION . . . ... . CITY ..... . . . . . .... CUPERTINO IMPACT AREA . . . ... . OWNER .... . . . . . . ... WONG JOHN C AND JUNE ADDRESS .. . . . . ..... CITY/STATE/ZIP . ..: BLUE BELL PA, CA 19422- RECEIVED FROM . ...: TIM CONTRACTOR . . . . ...: LIC q COMPANY ... . . . . . .. : ADDRESS .. . . . . . . ..: CITY/STATE/ZIP .. . . , TELEPHONE .. . . . . . . : FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ---------- ---------- __________ __________ BPERMFEE VALUATION 5,000.00 107.00 0.00 107.00 0.00 BSEISMICRE VALUATION 4,500.00 0.50 0.00 0.50 0.00 TOTAL PERMIT 107.50 0.00 107.50 0.00 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