99120087 3 s ZD q levo S�
PERMIT
APPLICATION'FOR CITY OF,CUPERTINO NUMBER
_ INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• IN DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS / L
RESIDENTIAL COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Clara A.
NAME✓! �fJ Qy ` roof assembly w required.
NO jg Inill I.C.B.O.N
ADDRESS(�fC� G� / EXISTING ROOF COVERING
PHONE (� E 3 6 07 NUMBER OF EXISTING COVERINGS
CONTRA�CTOO 'S,RR'/�
NAME �X y�g6- w4l. A Lv S' TO BE REMOVED s'li/� G' S TO BE RETAINED
ADDRESS7 `fie /G�J[V /I *,0 T�'PE F
CfT1'6 ZIP S��w K
EXISTING
PHONE Gtr S�� —3/5' fr oz. �7 777Ff BUILT-UP ROOF
NUMBER 707 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
7")ifDivblorrti 3 o tthBusiness dend Profession.� Coca nd may jlrosn.is fall with
and
SectionWOOD SHAKES
effect- WOOD SHINGLES
License Clew ✓ ue.Number 70'S ( ;�z` ❑
Cela T contractor OTHER(SPECIFY) ❑
y[ /\ '�R-theCoRDECIARATION PROPOSED
hereby alit Met I F m exempt from the s: Any city Lksnee Lew for the mewsafollowing permit
to
(Sec.70315.Business orad olish.or
Cade:sari
city pr aunty which requires to ❑
aorshud,ar .such prove,ermit to
a sign rep to em nt met e,p uceft is issuance,eosihandles the BUILT-UP ROOF /—�
apI Co far such permit m-a aChapt deterrent Nat he is th a Section
pursuant to die provolone n z-� D
of dee Cordredoro License Law(Chapter h(comm�met oven Section 7000)d ONolan 3 d the I - -
71
Buevtee9 eAr Professional f Coda)or That he o exempt amforefrom and the beats korhe athepp icant to ASPHALT SITINGLyDEC
❑
aFail pon.Anryf act ore Section h031.5 undred where
lorepermit subjects the applicant to /❑� 1
e avq penalty al rot more then INR hundred dollars If3oo).): 1�
99
C]1,as owner of the property,or my employees with wages as their ado compensation,will do WOOD SHAKES
the work,and ds fracture is m1 intended or offered for sale(Sec.7044,Business and Profas-
aims Code:The Contedors Uce.Law does net appy to an owner d property who builds or WOOD SHINGLE ❑
Improves,thereon,and who does such work himself or through h s awn empkryeee,preAded that
such Improvements are nor Intended or offered for sale.II,however,the bunking a Improvement
PL
—
issoldwithlnweyearolcompletbn,the owner-builder will he"the burden dpovingthat hedd OTHER(SPECIFY)
�f
not build or improve for Purpose of safe.).
❑I,as owner of the property,am exclusively connecting with Ikensed conlracton to construct
the project(Sec.7044,Business and Professkns Code:The Contactors License Lew does rot PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who Iffil or Irtproars thereon,and who comrade for such projects
with a contractor(s)licensed pursuant to the Contactwc License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.lot this reeeon
Owner - Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury we of the following declamation:
❑I neve anti will maintain a Certificate of Consent to segansure for Workers Compensation, �l P� Buildin
as provided for by Section 37W of the Labor Code,for the parfrm
aance Ne of work for which Was / g
permit is Issued.
❑I have and will melntaln Workers Compensation lnwlence,as required by Section 3700 of Seismic
the Lebon Code,for the performena al the work M which this permit is leeu /� 9, 3
CormPansellon Insymncpcanier end Policy number are: TOial(
Cartier cC�' �/j If�/Tfj Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0 ��////
(This section need not w completed If the permit Is for one hundred ddlere($100)or leas.) 2 i/K g
I cerfity that In the performance of the work for which this permit Is Issued,I shell net employ / 1
any pardon In any mammer so as to become cabled m me woYsars'Campanaeran Laws of Call. All roofs shall beInspected prior to any roofing material being
!amts. installed. If a roof is installed without first obtaining an
Data Appian inspection,I agree to remove all new materials for Inspection.
NOTICE TO APPLICANT: If,after making this Canwcete of Exemption,you should become A llcant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Coda,you must forthwith compy PP P Y
with such proAsons or this permit shall be deemed revoked. source regulations.
I cer ity that I neve read Tho epplicatlon and state met the above Informalbn Is caned.I agree
to comply wlth all city and county ordinances and state laws relafi g to building construction,and All roof Coverings to be classor better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In-
(We)agree to esus,Indemnity and Mcep hermleae the Cly of Cupertino against Ilebllltiee, r
Iudpma
ents,coats and expenses which may 1n any way scams against add City 1n consequence - SIGNATURE OF APPLICANT ATS
of the pr of this Permit. .
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
OFFICE COPY
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
• BUILDING PERMIT INVOICE OPERATOR: kareub
Sec: Tp: Rug: Sub: Blk: Lot:35620049.00,
INVOICE DATE. . ....: 12/14/1999
REFERENCE ID W ... : 99120007
SITE ADDRESS . .... : 11113 CLARKSTON AV
SUBDIVISION . . .... .
CITY ... . . . . ... ... : CUPERTINO
IMPACT AREA ...... .
OWNER . . . . . .. ... . . : CHU SHOW C AND PAT H
ADDRESS . . ..... .. . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4707
CONTRACTOR .... . . . : LIC 4
COMPANY . . .... .. . . :
ADDRESS . ....... . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE ..... . . . :
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- _________ ------------ -------_---
BPERMFEE P 107.00 0.00 187.00
BSEISMICRE P 1.30 0.00 1.30
--------- ------------ -----------
180.30 0.00 188.30
V� CE ID .......DESCRIPTION VOICE ID - DESCRIPTION
�.� . ........ ...... .................
FRAME 307 INSULATION
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS