12040090 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10803 NORTHOAK SQ CONTRACTOR:FOUR SEASONS ROOFING PERMIT NO: 12040090
OWNER'S NAME: KUNA SUNITA V AND PEDADA BALAKRISHN PO BOX 1668 DATE ISSUED:04/17/2012
OWNER'S PHONE: 4089963734 SAN JOSE,CA 95109 PHONE NO:(408)278-0330
❑ LICENSED CONTRACTOR'S DECLARATION r r r
7 BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class lr3 � Lic.N /Al Q�
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» MECH r RESIDENTIAL r COMMERCIAL r
Contractor 9EC Dale
1 hereby affirm that 1 am licensed under the provisions f Chapter 9 JOB DESCRIPTION: RE-ROOF TEAR OFF EXISTING CAI:SHAKE ROOFING
(commencing with Section 7000)of Division 3 of the Business&Professions SYSTEM,INSTALL COMP SHINGLES COLOR AND TYPE TO
Code and that my license is in full force and effect. MATCH EXISTING CLASS A 13SQFT
hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$6500
permit is issued.
APPLICANT CERTIFICATION APN Number:31641025.00 Occupancy Type:
I certify that I have read this application and stale that the above information is
correct.I agree to comply with all city and county ordinances and stale laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against Iiabilitirs,judgmenls,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-pointgulatims per the Cupertino Municipal Code,Section
9.18. s rc ..��
Issued by:--, L�f}TG{� Date: 17•%�
Signature Date
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property.or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Dale:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALI,ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Ceniliwac of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued, contaminants as defined by the Bay Area Air Quality Management District l will
I certify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of Cali fomia. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I most Owner or authorize
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.1 agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
3 ITEMS OF 15 PERMIT RECEIPT OPERATOR: patg
COPY' # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 31641025.00
DATE ISSUED. . . . . . . : 04/17/2012
RECEIPT #. . . . . . . . . : BS000016556
REFERENCE ID # . . . : 12040090
SITE ADDRESS . . . . . : 10803 NORTHOAK SQ
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : KUNA SUNITA V AND PEDADA BALAK
ADDRESS 10803 NORTHOAK SQ
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : FOUR SEASONS ROOFIN
CONTRACTOR . . . . . . . : DIAZ, ALFRED LIC # 21323
COMPANY .,. . . . . . . . . : FOUR SEASONS ROOFING
ADDRESS . . . . . . . . . . : PO BOX 1668
CITY/STATE/ZIP . . . : SAN JOSE, CA 95109
TELEPHONE . . . . . . . . : (408) 278-0330
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ---
1BCBSC VALUATION 6, 500 .00 1.00 0. 00 1 .00 0. 00
1BSEISMICR VALUATION 6, 500 .00 0.65 0. 00 0 .65 0 .00
1REROOFRES SQ FEET 13 .00 182 . 00 0. 00 182 . 00 0 .00
---------- ---------- ---------- ----------
TOTAL PERMIT 183 .65 0. 00 183 .65 0.00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 918 .25 #011834
---------------
TOTAL RECEIPT 918.25
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
309 EXTERIOR LATH 311 SCRATCH COAT
601 ROOF TEAR OFF 602 ROOF PLYWOOD NAIL
604 ROOF IN-PROGRESS 605 FINAL REROOF
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 10803 northoak square DATE: 04/16/2012 REVIEWED BV: bob s.
APN: BP#: 'VALUATION: $6,500
xPERMIT TYPE: Building Permit PLAN CHECK TYPE: Addition
PRIMARY SFD or Duplex PENTAMATION 1SFDWLR00F
USE: PERMIT TYPE:
WORK tear-off existing cal-shake roofing sysytem, install comp shingles Color and type to match exisitin .
SCOPE
;1J,•,:h. I'Inn C'h.rek Plumb. Plan Chcclr Fle,r.Plan Check
blrrlr. I;•rmli Fee: /'hunb. Pcrmir Fre: lihrc. Permit 140:
Other.11rch. Imp. Other Plumb Invi, Orhe, Elcc.Insp.
.We,h. ht,p. If Plumb. Insp. Fee: EIre. 1nsp. Frc:
NOTE: This estimate does not includefees due to other Departments(ie. Planning,Public Works, Fire,Sanitary Sewer District,School
District,etc. . Thesefees are based on the prelimina information available and are only an estimate Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 rf. 7/1///) FEE QTY7FEE MISC ITEMS
Plan Check Fee: $0.00 13 s.f. Re-roof
Suppl. PC Fee: (F) Reg. O OT FO,Q hrsRE I
$0.00 $14.00.'IREROOFRES
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee-.0 Reg. Q OT 0,0 hrs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
:Irliniuisfralive hire: Q
Work Without Permit? O Yes Q No $0.00 0
Advanced Plannine Fee: $0.00 Select aNnn-Residential Q
70-ave/lJoruurrnluliun Fuc•s:
Building or Structure O
Shone Motion Fee: 1BSEISMICR $0.65 Select an Administrative Item
Bldg Sids Commission Fee: IBCBSC $1.00
SUBTOTALS: $1.65 $14.00 TOTAL FEE: $15.65
Revised: 04/01/2012
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lease note that the rth Int Homeowner's Association nas zi
'�+: ontracted and,'appr (6d 'Ur.-Season's Roofing to penonn re- r
�. , •� r of7ij/lt Ih 1rl'.{' +II{1.1� i1Fl } I` y}�ilr`I 111 li�rl,ll�. I
1 oofidg of our h6M'in' Th will replace t6'current CAL Steaks
oo System with` A rand Canyo Asphalt Cagnposition
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the Stonew' color for iur rods
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REROOF PER.RIMIT APPLICATION 3�-O� 0091'
COMMUNITY DEVELOPMENT DERMITMEN1 - BUILDING DIVISIOP:
10300 TORRE AVENUE-CUPERTINO,CA 95014-3255 Ra
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LJPERT INO (408)777-3228.• FAX(408)777-3333- bullding(g),cupertino org
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SUPPLEMENTAL INFORMATION RE :D' OFFICE USE UNIA
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