99110069 AF
49//00 qv PERMIT
APPLICATION FORM CITY OF CUPERTINO NUMBER
_ INSPECTION DIVISION PERMIT EXPIRATION
' REROOF PERMI 1 - (408)777-3228 PERMIT EXPIRES IF NgRK IS NOT STARTED
• „ - WITHIN S F DAYOM S PERMIT ISSUANCE I OR
.. 'r
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS ,
L
W RESIDENTIAL COMMERCIAL OTHER
OWNER'S - .HAZARDOUS FIRE AREA
YES ❑ tt,yos—I understand that a Class A
NAMErequired.
NO ❑ Inm I.C.B.O.fF
ADDRESS S Q YYI 4L - EXISTING ROOF COVERING
' - - NUMBER OF EXISTING COVERINGS
PHONE
CONTRA T RKS �+,., '
NAME �CIS Reba O./d-/'s�(/IC.aTJX,4//��kAA ( -{J///�/� TO BE REMOVED /'� TO BE RETAINED
ADDRESS Y' D6W'/� I-/0/JCD t.GU LADE L.�.L•
TYPE OF ROOF COVE I
crTv s Zip , EXISTING co
PHONE ��J � BUILT-UP ROOF . Q
NUMBER `, ASPHALT SHINGLES
DCENSED CONTRACTORSsof Chapter
9(N
hereby affirm that em Business
licensed order Profession
d Chapter a(commencing with Section WOOD.SHAKES
7000)d Division 3 0l IM Business antl Pmfesalona Coda,and my Ilconee fe M IUB lone and '
effect.
�r39 Wil ' WOOD SHINGLES _
' LJcerlse Cleo Uc.Number G \
Date contract« OTHER(SPECIFY)
OWNER-BUILDER DECLARATION PROPOSED l � ,I
I hereby affirm Thal I am exempt from the Contractors Dcense Law for the following reason. KO 12 1999�p U
(Sec.7031.5,Business and Professions Cade: Any city or county which requires a permit to . IW O stew
construct,eller,Improve,demolish,or repair any structure,prior to Its leauerwe,also requires the ❑
eppllcem be such Permit to life a signed statement that he Is licensed pursuant to the provisions BUILT-UP ROOF
of the Contractors License Law(Chapter B(wmmencingg w%h Section 7000)of Division 3 of the
Business enol Professions Code)«that he Is exempt Iltarcho,end the beats for the alleged ASPHALT SHINGLES
exemption.Any volaton of Section 7031.5 by any applicant for a permit subjects the applicant to
a crAl penalty of not more than I"hundred dollars(5500).):
D1,as owner of the property,«my employees with wages as their We compeneatlon,will do WOOD SHAKES ❑
the work,antl Me structure Is not Intended ow offered f«sale(Sac.7044,Business and Pmlet-
sonsCode:The Contramrs1-cameichasnot appytoanOwner ofproperty whobuilde« WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that E]
such Improvements we not Intended or offered ler sale.If,however,the Wlldiag or Improvement
is said within one year of complellon,the owner-Wlldar will have the burden of proving that he did OTHER(SPECIFY) Elnot WIW or Improve for purpose of eels.).
I,as owner d the property,am exclusively contracting with licensed contractors to conetmcl
Me prolect(Sec.7044,Business and Professions Code:The Contractors License Law deals not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of properly who mica or Improves thereon,and who contracts for such projects
wnh a contract«(a)licensed pursuant to the Contractors License Law. PROVIDE MFGR.I TION SPECS.
❑I am exempt under Sac. ,B It P.C.for MIS reason
Owror oats APPLICATI DATE VALUATION PERMIT FEE
WORKERS COMPENSATION DECLARATION
I hereby aHlrm under penalty of penury ane of Me fallowing declaration. -
D I have end wtll maintain a Cortnlwto of Ca t 10 Wf.insure for Workers Compansaton, Building
as provided for by Section 3700 of the Leber Code,for the performance of the work for which this
permit Is issued.' Seismic
D I have and will maintain Workers Compeneatlon Insurance,as requ l rad by Snctlan 3700 of a O
the(Labor Cade,for the padormanca of f work for which this.Permit Ie issued.My Workers / Total.
Comite don Insurance corder end Po i nu leer ar
Carrler
4 uw'Na. gT6E �°z PER IT AUTHORIZATATE
CERTIFICATE OF EXEMPTION FROM WORKERS'-
COMPENSATION INSURANCE N.CQ
(This section need net be completed d the permit Is ler one hundred down($100)or lees.)
I tartly that In the pe rmanca of the work ler which Mle p«mX Is issued,I shall not em
any person In any manner so as to become sublect to the Workers'Co nomoatbn Laws of All roofs shall be inspected prior to any roofing material being
romle. - installed. If a roof is installed without first obtaining an
Date Applicant - inspection,I agree to remove all new materials for inspection.
subject to throw��s'CoTm�paf�ilon proaalo Is of tihe LLaatbor Cof odeyou you forthwith omplY Applicant understands and will comply with all non point
with such provisions or MIs permit shall be deemed revoked. Source regulations.
I certify met I here react this appllca ion anal elate that Me above Information Is correct I agree
tocompy with all dy and count'ordinances and stale laws relating to building consWclion,and .All roof co-VaFwqgs to be class"C"or better.
hereby authorize representatives of this city to enter upon the aboke-mentioned property ler In-
spection
n-
aP(We) aureate.. '//I(/.f
(We)agree to gave.In nsaus w and keep harmless the Cly Of st said
against IleGlllles,
of the gnis,coeie and expenses which may In any way accrue against sold Ciry M mreequence
of the grantlng d this permit. E OF A C 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: nancyc
Sec: Twp: Ing: Sub: Elk: Lot:36922014.00
INVOICE DATE. . .... : 11/12/1999
REFERENCE ID # ... : 99110069
SITE ADDRESS ..... : 1077B E ESTATES DR
SUBDIVISION ...... .
CITY ... . . . . . ..... : CUPERTINO
IMPACT AREA . ..... .
OWNER .... . . . . . ...: COFFIN THEODORE Q AND VIOLET L
ADDRESS . .. . . . . . . .:
CITY/STATE/ZIP . ..: CUPERTINO CA, CA 95014-4534
CONTRACTOR . . . . . . . : RADONICH, GARY LIC # 17814
COMPANY .. . . . . . . . . : LOS GATOS ROOFING
ADDRESS ... . . . . . . . : 1771 SMITH AVE
CITY/STATE/ZIP . . . : LOS GATOS, CA 95030
TELEPHONE ... . . . . . : (408)358-1233
FEE DESCRIPTION CHK TOTAL FEE PAID-TO-DATE BALANCE DUE
--------------- --- --------- ------------ -----------
BPERMFEE P 137.00 0.00 137.00
BSEISMICRE P 0.80 0.00 0.80
--------- ------ ----- -----------
137.80 0.00 137.80
V ' ID ------_-DESCRIPTION---__-___ VOICE ID ._a DESCRIPTION
5 FRAME 307 INSULATION
601 - ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
603 ROOF BATTENS 604 ROOF IN-PROGRESS