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99110047 3.3 l 7 O o f noq PERMIT APPLICATION FOR CITY OF CUPERTINO NUMBSIF REROOF PERMIT INSPECTION DIVISION PERMIT E) ATIDN (408)777-3228 PERMIT EXPIRE80 S IF aeaMlT ISSUANCE icoa 180 DAYS FROM LAST CALLED INSPECTION. BUILDING ADDRESS J) y�// J 1 / vI/T r;7' RESIDENTIAL COMMERCIAL OTHER OWNER'S - HAZARDOUS FIRE AREA 2 /� z / YI /, li/J,n'// VES ❑ Ryes—Imblyisequire . Class NAME CJ�1/lily! (a/L�L f'T!/'G5 roots—I understand ry required. NO ❑ Irill I.C.B.O.p ADDRESS ,/0/ 70 EXISTING ROOF COVERING PHONE - O NUMBER OF EXISTING COVERINGS CONTRACTOR'S NAME��N LON ✓L� �Q'V�-//fI rJ TO BE REMOVED 70 BE RETAINED ADDRESS3 Gam/ ���SOS6 TYPE OF ROOF COVERING CITY&ZIP�7l� yt/OOOs> 4-1FJCIS I ING PHONEQQ 0%J �SZZ BUILT-UP ROOF LICENSE NUMBER . ASPHALT SHINGLES / LICENSED CONTRACTORS DECLARATION hereby asi nn tial I em si licensed under provbbre of Chapter a(coma e1.In with Section WOOD SHAKES ]000)of OlWeion 3 of the&ulrress entl Proleeslone Cade,and my license Ie In lull lerco and Lk.Number DcenIcer ee Close C 3y -7/ 3z WOOD SHINGLES ❑ �� l Dab .Contractors I CDA) UA% AV6.rt, OTHER(SPECIFY) ❑ OWNER-BUILDER DECLARATION 19 0PROPOSED I hereby affirm Nat I am exempt from the Contractor'.License Law for be following reason. (Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to construct,after,Improve,deal or repair any structure,prior to Its issuanco,also requires the BUILT-UP ROOF applicant for such permit to file a signed statement that he Is licensed pursuant to the prordians „ of sin ss and ors License Lew(Chapter h IfTs sa n�]�ol n 3 T SHINGLE$ ex Business end Probsslnof Sectio or that he I.e om e exemption.Any Wobtion of Section]W 1-.5 by arty Ilcom a p H t t t D e dmf panauy of not more man nVe huotlnad dale S850o).):` SHAKES 0 ❑I,as owner of me property,or nny employees wages Ir on, © D the work,and the dmdura Is not interdetl or offered for sale(Sec.]09Businese eM Prole - I m Improves Code.This Contractor's License Lew tloee not ap�fy to an n {��1laa a OD SHINGLES NOf(] (� �99f1 Imprwae tM1ereon,and who daea such work himself or 1ryry ugh hempl 9 J each Improomenb are not intended a olleretl br eels�1J howevaT �G��n r mgr blob wilNn erre year of campletlon,the owner-Wltlar yl�VS plq bZOO". e - ER(SPECIFY) ❑ not Wild w Improve for purpose of sale.). ❑I,as owner of the property,am exclusively c a t 8y the project(Sec.]044,Business add Proo"10 h a e n I.C.B.O.REP T=NO. apply to an owner of property who Were or Ini with a conbedor(s)licensed pursuant to me Con do E MFG R. INSTALLATION SPECS. ❑I am exempt under sec. ,B d .C.Wtide reason owns+ oats WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE - I hereby affirm under penalty of perjury one of the Iollowing declarator: ❑I have entl will maintain a Certificate of Consent to sell-Insure fur Worker's Cornpensatlan, Building provided for by Section 3]00 of the Lebar Coes,for the performance of the work for which this �� v Permit Is Issued. Seismic [:]I have and will maintain Worker's Compensetlon Insurance,as required by Sectlon 3700 of iO the Labor Cade,for the perfonnanco of the work for which Ills permit Is Issued.My Worker's •/-/r Compensation Insurance carrier and Policy number are: Total / 1 Carrier Policy No. PERMIT AUTHORIZATION DATE CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE N.c.❑ (This Becton need not be completed H the permit Is for one huraf dollars($100)or lase.) I codify that In the performance of rhe work for which Ills permit is issued,I sitar' any person in any barterer so as to become suf>led 1 a worker.campon we of Call- All roofs shall be inspected prior to any roofing material being fordo. installed. If'a roof is installed without first obtaining an Date J�_I—L Alms ant inspection,I agree to remove all new materials for inspection. NOTICE TO APPLICANT: It,after mak Xis r s o Eemption,you should became Applicant understands and will comply with all non point Subject to the Workere Compensaton provisions 1 L ,you must fortirwlth comply PP P Y with such provisions or this Permit shall be deeroe ked. source regulations. I ceNty that I hays react We application and state mut the above information is cornd.I agree ,,�/��L to comply with all city and county ordinances and state laws relating to bulltlingconetruction,and All Dverings to be class p�Ur better. hereby authorize representatives of this dry to enlor upon the above-bromfO ed property for In- spection purposes. .- J (We)agree to save,-Indemnify and keep harmless the City of Cupertino against Ilatelllfles, r �.' lud menta,costs entl expereas which they In airy way accrue against said Clry In consequence of iR0 granting of this permll. SIG ATU FAP CANT DATE PRE-INSPECTION: PLYWOOD: "r IN-P DRESS: 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: christYa Sec: Twp: Rng: Sub: Blk: Lot:32617013.00 INVOICE DATE......: 11/09/1999 REFERENCE ID k ...: 99110047 SITE ADDRESS .....: 10170 AMELIA CT SUBDIVISION ...... . CITY .......... ... : CUPERTINO IMPACT AREA....... : OWNER ............ : GRAVES BEULAH TRUSTEE ADDRESS ....... . . . . CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-1066 CONTRACTOR ... ....: LIC k COMPANY ... . .. ....: ADDRESS .. . . ......: CITY/STATE/ZIP .... , TELEPHONE ........: FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE . _______________ ___ _________ ____________ __ BPERMFEE P 77.00 0.00 77.00 BSEISMICRE P 0.50 0.00 0.50 _________ ____________ ___________ 77.50 0.00 77.50 V ID ------- DESCRIPTION-----.--- VOICE ID - DESCRIPTION - FRAME 307 INSULATION 601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL 603 ROOF BATTENS 604 ROOF IN-PROGRESS s