99080209 �'qo g ora
3,2 — q7-017 PERMIT
APPLICATION FOR CITY of CUPERTINO NUMBS
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 S /L n
/a3`T'o
_ RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
L��� YES ❑ If yorefe
—I urKLrsnd Ihef a Glass A
NAME '� �/. rod assembly is required.
NO ❑ hfial I.C.B.O.i
ADDREss '�� EXISTING ROOF COVERING
" PHONE 25 NUMBER OF EXISTING COVERINGS
CONTRAC sa A9 /
TO BE REMOVED TO BE RETAINED
NAME /'�
ADDRESS 7.j/D /�.(tiQ I n,. . TYPE OF ROOF I
crvazl cW,^/� ciS3� EXISTING
PHONKAPF� 779' i' BUILT-UP ROOF ❑� z2 �
LICENSE '/C
NUMBER �3 S� ASPHALT SHINGLES ❑ S 7
UCENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under proAeero of Chapter a(commencing with Section WOOD SHAKES
7000)of Dlvlelon 3 of the Business and Professions Code,and my license is In lull force end
ct.
effe '[
ss`/35� WOOD SHINGLES ❑
Ucanse Clean Uc.Number �-}
y� omrachor OTHER(SPECIFY, ❑ I
Oete -BUIUOE
OWNER-BUILDER DECLARATION PROPOSED '1r
hereby affirm that am exempt ions the e: Any city License Lew for re brewing reason. �UU 3 0 199ea
(Sec.7ct,sit Business and Professions Code: Arty city or county l requires a permit to ylL�1
construct,erten.Improve,damolla siorrepairanystructure.prior toue Isauauantalso eequtresthe BUILT-UP 00
of the contractor's
permit to La (Chaptr9(coentthat he Is licensed purspenf to the pm of
of the ss and Prof scionsicense Lew(Chapter a is ex a pt I with Section 7000)of for lor,the 3 of the
Business end Professions Cade)or that he le exempt therefrom end the basis for the alleged ASPHALT SHINGLES (-,�L/s./�_
exemption.Arty vlOstfon of Section 7031.5 by any applicant for a permit subjects the applicant to u /
e civil penalty of not more then five hundred dollars($5001.): �.y - —�•
C)1.as owner of the property,or my employees with wages as their a ole comperma0on,will WOOD SHARES ❑
the work,and the stwoure is not Intended or offered for sere(Sec.70",Business and Proteins.
Blom Code:The Contractor's License law does not appy to an owner of property who bulbs or WOOD SHINGLES
Improves thereon,and who does suit vid
work himself or through his own employees,proed that El
such Improvements are not Intended or offered for sere.If,fwwarer,the Wlkling or Improvement wn D I
Is sold whhln me year of completion,the owner-builder will have the burden of prof that he did OTHER(SPECIFY)
not Wild or Improve for purpose of sale.).
❑1,asownerolthepmpery,emaxdusl"tycmtma Ir�g wlthlbamadcmtractorstoceMlnlLl
the protect(Sec.7044,Business and Profession,Code:The Contractor',Uca so Law does not 'PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Wilds or Improres ttrorson,and wino contracts for such projects
with a contrectoge)Ikansed pursuant to the Comrector's Ucome Lew. PROVIDE MFGR.INSTALLATION SPECS.
0 I am exempt under Sac. .B B P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
i I hereby affirm under penarty of perjury one of the foikrming declaration:
❑I hese and will maintain a Certificate of Consort to sal inure for Worker's Compensation, O Building
as provided for by Section 3700 of the Labor Coda,for the per imance of the work for which this aLs� g
perm aIssued. 7DY`e�/�'�/�' ///, 4r� (O Seismic
I have and will maintain Worker's Compensatlon Insurance,as required by Section 3700 of
t Labor Code,for the perormence of the work for which this permit Is Issued,My WorkeYe A
'Com abor Cod ,f r the order and of i mbsr era: +/� Total �
Carrier .5 k4li PoIIoyNo.� I��� PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section need not be completed If the permit Is for one hundred dollars($100)or foss.)
. I certify Net In the performal of the wank for which this Permit Is Issued,I,heti not employ
an person In m 11 eo as to become subs 1Q Ne e a comps eaten awn of call- All roofr,shall be inspected prior to any roofing material being
/ Ol installed. If a ,roof is installed without first obtaining an
Data AppOcem inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: It,after making this Car-Iffit of Examptim,you ahwW become Applicant understands and will comply with all non point
subject to the Workers'Compensation pp co
hsons of the Labor Code,you must forthwith mply
with such provisions or Nle permit sftelGbe deemed revoked. Source regulations.
I ceNly Net I have r"d this applil and state Nat the above Information is mmect.I agree I��{1,.
to campy with all city and county ordinances and state laws relating to Wlldlrvg construction,and All roof Covert to be C17 y or better.
hereby authorize repreemtal of the city to enter upon the above-mentorned property for In. VVV
,pacaon purposes.
(We)agree to save,Indemnity and keep harmless Ne City o1 Cupertino agakat IlebNtles,
Judgments
f the gratn'tingaof this pseamnit�s which may In any way sows against sans Clyl.,coneequance SIGNATURE APPLICANT DATE
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP. DAT INSP, DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE.COPY
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE 'INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: christya
Sec: Twp: Rng: Sub: Blk: Lot:32647017.00
INVOICE DATE......: 08/30/1999
REFERENCE ID # ...: 99080209
SITE ADDRESS ... .. : 10390 STOKES AV 1
SUBDIVISION ...... .
CITY ......... . . . . : CUPERTINO
IMPACT AREA . . . ....
OWNER .... . . . . ....: LORENZ DANIEL A AND ANNETTE P
ADDRESS .. . . . .....: .
CITY/STAT£/ZIP ...: CUPERTINO CA, 95014-1232
CONTRACTOR .......: LIC #
COMPANY . . ........:
ADDRESS .......... :
CITY/STATE/ZIP . .. ,
TELEPHONE ........ :
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- _-- --------- ------------ _----------
BPERMFEE P 157.00 0.00 157.00
BSEISMICRE P 1.00 0.00 1.00
--------- ------------ -----------
158.00 0.00 159.00
VID DESCRIPTION--.------ VOICE ID ------- DESCRIPTION
.. ......n ........ ........ ...............
305 FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS
•
CITY OF CUPERTINO
1 of 1 BUILDING PERMIT RECEIPT OPERATOR: Christy&
COPY N 1
Sec: Twp: Rug: Sub: Elk: Lot:32647017.00
DATE ISSUED. ......: 08/30/1999
RECEIPT N. . . ......: 9928
REFERENCE ID # ...: 99080209
SITE ADDRESS .....: 10390 STOKES AV
SUBDIVISION ...... .
CITY . . ........... : CUPERTINO
IMPACT AREA ...... .
OWNER ............ : LORENZ DANIEL A AND ANNETTE P
ADDRESS ....:.. . . .
:
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-1232
RECEIVED FROM ....: TIMO
CONTRACTOR . . .....: LIC M
COMPANY ... . . .....
:
ADDRESS . . . .......:
CITY/STATE/ZIP ... . ,
TELEPHONE . ....... :
FEE ID UNIT QUANTITY AMOUNT PD-TIO-DT THIS REC NEW BAD
---------- -------- ---------- _ __
BPERMFEE VALUATION 10,000.00 157.00 0.00 157.00 0.00
B. SMICRE VALUATION 10,000.00 1.00 0.00 1.00 , 0.00
1 PERMIT IS8.00 0.00 150.00 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ -------"
CHECK 158.00 10177
TOTAL RECEIPT 150 00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
...,..... ...................=n....... ........ ............................
305 FRAME 307 INSULATION
501 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
,603 ROOF BATTENS 604 ROOF IN-PROGRESS
•