08060157 (2) CITY OF CUPERTINO a• ; ::. *d -�-,
BUILDING DIVISION PERMIT 000N'TRACTOR�INFORMATION
BUILT6921ITTLENCOE DR ADVANCED ROOFING TECHNIQUES 08060157
OWNER'S NAME: PERMIT IS UE DATE
JIM KOREN 15272 STRATFORD DR 06/23/2008
NE:
(408) 249-4937 SANITARY NO. CONTROL NO.
ARCHrrECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
00 o LICENSED CONTRACTOR'S DECLARATION Job Description
m 1 thereby affirm that 1 am Ines ucd under provisions OeSCTI of Chapter 9(commencing P
with Section TWO)of Division 3ofthcBusinessand Prornerm.Cd hansom RE—RF T/OF EXTNG SHKRF INSTL 1/20SB 30#FLT INSTL
din sen r.rce.rad erre Y
�q= Lkemc( Lc.g CLSA TILE- 20SQ
e t- Dale t L
Conln-
I ARCHfTELTS DEC ATI
W6
I mdvstand mY plans shall W used as public records
o t; Licensed Pmfcssi...I
OWNER-BUILDER DECLARATION
5: 1 Wrchy affirm Not I am exempt from the ConvazloYa License law for tiro
0 o fallowing mason.(Section 7931.5,Business and Pmfeson oCade:Any cityor..my
12 9 which nquiro a permit to construct.alcor,improve,dcmnlish,or repair any structure
Lzi Prim to its issuance.also hequims the applicant for such permit to file a signed autemenl
p < that he is limned reform t.the pmvismeam'Nc Cartoon,]License Law(Chapter 9 Sq.Ft. Floor Area Valuation
y (eommurcing with Sees.7000)of Division 1 of the Business and Profusions Cade)or $8000
CRE$ thai he Is excmpt IMsefrom and the basis for the alleged exemption.Any violation of
Section 7051.5 by any applicant for a permit subjects the applicant N a civil penalty of p�7 Number Occupancy not roam then five hundred dollars(5500). 3 2 6 3 010 8 .4' ` P y TyPe
I,we owner of Ne property,or my employees with wgu as their In compensation,
will do the work and the trwcture IS not intended or.ffemd for sale(Sec.1(s14,Bummus
and Profession Code:The m
Conttacrt.
a L .Law does so tapply m an owner of Required Inspections
Property,wW Wilds or improver,Nunn.and who don such work Waselfon through his
own employcn.provided that such improvements an not interisland or offend for sales IL
however.the Wilding or Improvement is sold within am year of completion,Ne owner.
builder will base the When of proving Nat W did tot Wild Or improve for purpose of
sale.).
❑1,as owner of the property am exclusively convecting with licensed mnuactan to
mntroct the project(Sec.7044,Busimv and Profession Code:)The Connacbh Li-
cem law does oat apply man..mof property who Wilds or improves Norton,and.
w W convects for trach projects with.convacmrts)livened perauam in the Cotvevine,
License law.
[j I em exempt under Sec ,B k P C forties moon
Owe Dau
WORKER'S COMPENSATION DECLARATION
1 hereby alien under Nulty of perjury one of the,following declaration:
I ham and will maintain aCeniftom of Consent self-inu,for Workch Compen.
amion,u provided for by Section 1700 of the labor Code,for the performance of the
work for which Nis permit is issued.
Ehens and will maintain Workers Composed..Imran¢,as undrsM by Section
of the LaWr Coda for the performance of the,work for which this permit u Id. s
My Wor ompewtio suranee trim and Polity number art'
tinier. Polity No,I TIA.LQ�
CERT] ICA OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This Section need not W completed if the permit is forme hundred dalton(5100)
orleu)
1 calory trot in than perfoenmme of tW work for which Nis permit u issued.I"I not
employ any person in any manner an an in become wbject to the Workers'Compenati.n
Laws of Cs ifomia Date
Applicam
NOTICE TO APPLICANT:If,after making this Cerufcam of Exemption,you should
become subjem in the Workers Continuation provisions or she labor Code,you most
.J O forthwith comply with such provitiou m Nu resod shall W deemrA newked
'zy CONSTRUCTION LENDING AGENCY
[-v I kleby Ifffmh Nat Nen Lia construction lending agency for dm Performance of
Ci> Ne work for whim this Permit le issund(Sec.3097.Civ.C.)
W� Leader's Name
a z l<ndce.Address
V Q 1 certify that 1 have read Nie applicaden and sun thal the aWw information u
casco.1 agra n comply with all city and county.Nin ones and scam law relating to
.I] building construction,and hereby auNarim representative or Nu city N mic"No the
E
[Tl slaw-mctudgm judgmepromernts.cam
for inpcctj.n puryous
0. (We)agree to save,indemnify and keep harmless the City of Cupertino armed
fq in
gjuce Ofth.cmuang oxpenwswhich may in any wyacerue agent mid City
t.)z A PIXANT of the grassing SNis permit
^ APP ANT UNDERSTANDS WILL COMPLY WITH ALL NON-P Issued by: Date
50 REGU�LA�TISp.
IAPB 0'--Q Re-roofs
Shgnuwe�ol App tan ntramor Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or future Wilding Dmvpardt ore or handle haumou material
So defend by Nc Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Code.see yea 15532(a)? All roofs shall be inspected prior to any roofing material bei.
❑res � being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hevaMn
sur conumiunu as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yu 1No
I have mol the�mamr mWcmettautder Clfpmr6.95 of Ne Califon- /\'�, ,, u
nice HCmthAsalmyGDde,Seetionu255f15,255EJend155Jd.1 undleortand Wilding y ^
dao t &SaIcY haw a ocaor Nm h u 55 responsibility un ramify the aidthe of dm C A 1 AA
MAwhich rat me helm mmc.ra Ccmkmcml .upmy. Signature of Applicant Date
�- � l� a (, All roof coverings to be Class'4!'or better
Owner or mNom<d age I Dam'
CITY OF CUPERTINO
• 2 ITEMS OF 2 PERMIT RECEIPT OPERATOR: patg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN 32630108 : 00
DATE ISSUED. . . . . . . : 06/23/2008
RECEIPT # . . . . . . . . . : BS000005192
REFERENCE ID # . . . : 08060157
SITE ADDRESS . . . . . : 10439 GLENCOE DR
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : JIM KOREN
ADDRESS 10439 GLENCOE DR
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : SCARLETT L ORSBURN
CONTRACTOR . . . . . . . : ORSBURN, DUANE LIC # 21245
COMPANY . . . . . . . . . . : ADVANCED ROOFING TECHNIQUES
ADDRESS . . . . . . . . . . : 15272 STRATFORD DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95124
TELEPHONE (408) 249-4937
• FEE ID UNIT QUANTITY AMOUNT . . PD-TO-DT THIS REC NEW BAL
-------=-- ------------- ---------- -`-------- ---------- ---------- ----------
1BSEISMICR VALUATION 8, 000 . 00 0 . 80 0 . 00 0 . 80 0 . 00
1REROOFRES SQ FEET 20 . 00 260 . 00 0 . 00 260 . 00 0 . 00
---------- ---------- ---------- ----------
TOTAL PERMIT 260 . 80 0 . 00 260 . 80 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 260. 80 MC
---------------
TOTAL RECEIPT 260 . 80
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
•
CITY OF CUPERTINO
, REROOF
CUPEkTINO PERMIT APPLICATION
APN # Date:
a 3v l o 0o LP-a3 -og Address: I0
4?)q n 1
Dr
Owner's Name: JVy-� Koren Phone #: LO—t44ko-6�4a
Contractor: 1A,6VGkjjC(fly�� TLCk Phone #: L4N-�qq-
' J Fax #: (4U - p -p o
Cupertino Business License #: Contractor License #:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
X Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles _
❑ Other (Specify) I�C Other (Specify) LIle
Number of existing coverings ❑ Provide I.C.B.O. R ort #
)C To be Removed ❑ Provide Mfgr. Installation Specs.
Job Description: -TCS, Ock- _e_ etsh skck-Lk r ' ✓4Sir'L-1 I yZorsb,
3buF 4A 1 rvsv" h UP- (f z A /--
Residential Commercial ❑
Green Building: Please complete relevant portion of the Confinned with Planning Dept. if
Green Building Checklist& attach it to the application or if there are any restrictions: ❑
applicable, include in plan set & the sheet index.
Valuation:
• I Have ,�,Read, Understand and Will Comply with Cupertino's Tear-Off Policy:
—� Ad s
Signature
Revised 6/16/08
CITY OF CUPERTINO
51�1 REROOF
• CUPEkTINO FEE SCHEDULE
Number of Fee ID Fee Description Fee Permit Type
Squares Group
1REROOFCOM Re-roof Commercial B 1COMMLROOF
1BSEISMICO Seismic Commercial B
1 REROOFRES Re-roof Residential B 1 SFDWLROOF
/ 1BSEISMICRE Seismic Residential B
1RER00FMRES Re-roof Multi-Family B 1MFDWLROOF
1BSEISMICRE Seismic Residential B
1BUSLIC Business License B
Revised 6/16/08
•
Community Development
10300 Torre Avenue
Cupertino CA 95014
y Telephone(408)777-3228
CITY OF Fax(408)777-3333
4UPEI�TINO
Building De artment
JOB,ADDRESS: PERMIT #
0 f U� � � o1S '-7
OWNER'S NAME: n PHONE # y -
GENERAL CONTRACTOR: c.ed. FAX #
I am not using any subcontractors: f LQ1 03-
a
Signature Date
Please check applicable subcontractors and complete the followinginformation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum / Wood
• Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
4SPlastering
lumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
k-0 0V
Owner/Contractor Signature Date