991000320
41
L( I �Q ZZJ
OFFICECOPY
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 7%%-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
' WITHIN 180 DAYS OF PERMIT ISSUANCE. R
180 DAYS FROM LAST CALLED INSPECTION.
OUILDING ADDRESS
8/0 ��"r�-�---
+} c�ft 0.P .
'
RESIDENTIAL COMMERCIAL OTHER
OWNER'S
tJAZARDOUS FIRE AREA
Do
• - ��
YES ❑ no yes andreq that a Class A
NAME f.. � �.G.(7
Is
rrtby required.
NO ❑ _ Initial- LC.B.O. R
�4iiii
EXISTING ROOF COVERING
ADDRESS
� /
PHONE —/05 o
NUMBER OF EXISTING COVERINGS
/
CONTRACT ETA
J
TO BE REMOVED 70 BE RETAINED
NAME
ADDRESS
` TYPE OF ROOF COVERING
_
CITY 8 ZIP �pG LCY.f�
X TING
PHONE S4�r3 �6. 3 ] 3
BUILT-UP ROOF
LICENSE
�p�� 017
...///
NUMBER OO
ASPHALT SHINGLES.
LICENSED CONTRACTORS DECLARATION
fwrf affirm that am licensed under erosions of Chapter 9 (commencing with Section
WOOD SHAKES ❑
Di ato
]000) of DIvL4on 3 of theBusirndss end Professions Code, and my license b in lull force and
in
,
affect.
z Qo
WOOD SHINGLES / C�Ty/
License CI Uc. Number
J
Q
OTHER (SPECIFY) ❑
Date Contractor
OWNER -BUILDER DECLARATION
PROPOSED
I hereby affirm Met I am exempt firm the Convectors License Lew for the following reason.
(Sec. 7031.5, Business and Professions Coda: Any city or county which requires a permit to
constimt, alter. Improve, tlemolleh, or repair any structure, prior to Its Issuance, atso requires the
BUILT-UP ROOF
applicant for such permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Lew (Chapter.9 (commandr�g with Section ]000) of Division 3 of the
Business and Profession. Corte) or that he Is exempt therefrom and the bests for the alleged
ASPHALT SHINGLES ❑
wamptm. Any violation of Secdon 7031.5 by any applicant for a permit subjects the epplfcant to
.-
e civil penalty of not more than five hundred colors (5500).):
❑I, as owner of the property, or my employees with wages as Meir WIG cornpensaticn, will do
WOOD SHAKES ❑ ,
the work, entl the structure Is not Intended or offered for said (Sec. 7004, Business and Profes.
alms Code: The Contractors Ucence Law does not appy to m owner of property who Wilds or
WOOD SHINGLES
improves therem, and who does such work himself or through his own employees, provided that
_ ❑
such improvements are not Intended or offered for sale. If, however, Me Wilding or Improvement
Is Who wthin one year of canpleWn, the owner -Wilder will have the burden of proving that he tlb
OTHER(SPECIFY) SPECIFY) ❑
net bulb or Improve for purpose of sale.).
01, as Avner of the property, sin exo'usivey cmtmctirg with kcersed matmctos to construct
. the project (Sea 7044, Business and Prufesebns Coda: The Cmtmctors License Low does not
PROVIDE I.C.B.O. REPORT NO:
appy to an owner of property, wind Wilds or Improves therem, and wind contracts for such projects
with a cdntrardoi(s) licensed pursuant to the Contractors License Lew.
PROVIDE MFGR. INSTALLATION SPECS.
❑ 1 am exempt under Sec. ,B 6 P. C. for the reason
owner Date
WORKER'S COMPENSATION DECLARATION
APPLICATION DATE
VALUATION
PERMIT FEE
I hereby affirm under Penalty of perjury me of the following declaration:
Cl I have and will maintain a CetllHcate of Concent to seffdnsure for Workers Compensatlon,
BBprovbnd for by Section 3]00 the Labor Code, for
� J
/
Building
g
of me perbrrrtertce of rine work for which this
permiteve
/O /c/
i
_/-/_
(f`((,(_)
and
have entl wool Workoe Compensation insurance,hthis pare by Section 3700 of
S/✓
Seismic
the pert
Ih Labor Code, for the perlormance of the work for which thle permit a issued. My Worker's
is i
C mpers�ation In corner nd PoII umber ere:
Total
�re^�{
GonerPolicy No. C57 ..
PERMIT AUTHORIZATION
DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
X
COMPENSATION INSURANCE No
(This section need not W completetl if the permit H for ma hundred dollars (5100) or bee.)
I Wri fy that In the performance of Ne work for which this permit is Lasued
IV
All roofs shall be inspected prior to any r ting material b ng
any conical N cry manner so as to become subject to the Wor Compmsatbn Lawn of Cog-
1unfo'
/G
installed.. If a roof is installed without first obtaining an
Date 45 t Applicant
inspection, I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: If, after making this carlBicatef Exemption, you shoWd become
subject to the Workers' Compensation provisons of the Labor Code, you must forthwith wrnpy
A titans understands and will comply with all non point
pP P Y P
with such provisions or the parrrkt shell be doomed revoked.
source regulations.
I witty that I have read this application and crate that the above Information Is correct I agree
to campy with all city and county odiawceB and state laws Glaring to Guiding concoction, and
All roof coverings to be CIaS or better.
herebyn purposes. ze representatives of this city to enter upon the above-mentionetl property for In.
herCbe nuthmi9ee.
/ ^ n
(We) agree to save, Indemnity and keep harmless the City of Cupednci against Iiablllties,
/rLJ !'•/--s6//"//
ludgmens, coats and expenses which may In any way accrue against said City In consequence
of Mo ginning of this pereft.
SIGNATUR5,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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICECOPY
• ' CITY OF CUPERTINO
It,. 1 of 1 BUILDING PERMIT RECEIPT
Sec: Tp: Rng: Sub: Blk: Lot:37541022.00
DATE ISSUED.......: 10/07/1999
RECEIPT q.........: 10261
REFERENCE IO q ...: 99100032
SITE ADDRESS ..... : 810 STENDHAL LA
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OPERATOR: nancyc
COPY k : 1
OWNER ............: WONG TZE K ET AL
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4628
RECEIVED FROM ....: TIM
CONTRACTOR .......: COSMOS, RICHARD LIC q 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 -TO -DT THIS RIC
BRMFEE VALUATION 7,000.00 127.00 ------ 0.00
-- 127.00
MICRE VALUATION 7,000.00 0.70 0.00 0.70
TOTAL PERMIT 127.70 0.00 127.70
METHOD OF PAYMENT AMOUNT NUMBER
__________________
CHECK 127.70 10383
------------
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
NEW DAL
0.00
0.00
0.00
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
FEE DESCRIPTION
BPERMFEE
BSEISMICRE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE
Sec: Twp: Rng: Sub: Blk: Io :37541022.00
INVOICE DATE......: 10/07/1999
REFERENCE ID N ...: 99100032
SITE ADDRESS .....: 810 STENDHAL LA
SUBDIVISION .......
CITY .............. CDPERTINO
IMPACT AREA .......
OPERATOR: nancyc
OWNER ............: WONG TZE K ET AL
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO CA, CA 95014-4628
CONTRACTOR .......: COSMOS, RICHARD LIC 4 18844
COMPANY ..........: COSMOS ROOFING
ADDRESS ..........: 450 ,SAN ANTONIO RD
CITY/STATE/ZIP ...: PALO ALTO, CA 94306
TELEPHONE ........: (415)493-6373
CHK
P_
P
ID DESCRIPTION
........ ..........e.e......
305 FRAME
601 ROOF TEAR OFF
603 ROOF BATTENS
E
TOTAL FEE PAID -TO -DATE BALANCE DUE
_________ ____________ ___________
127.00 0.00 127.00
0.70 0.00 0.70
_________ ____________ ___________
127.70 0.00 127.70
VOICE ID DESCRIPTION
........ ........ ............................
307 INSULATION
602 ROOF PLYWOOD NAIL
604 ROOF IN -PROGRESS