12050106 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20205 NORTHGLEN SQ CONTRACTOR:FOUR SEASONS PERMIT NO: 12050106
ROOFING
OW'NER'S NAME: STEPHANIE LU PO BOX 1668 DATE. ISSUED:05/11/2012
OWNER'S PHONE: 4082748033 - SAN JOSE,CA 95109 PHONE NO:(408)278-0330
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL COMp1ERC1AL.
License Class C 3-/ Lic.p 70210'0 RE-ROOF 13 SQ-TEAR OFF EXISTING,CAL SHAKE
yS�L ROOFING SYSTEM, INSTALL 3011 FELT UNDERLAYMENT
Contractor^/ Date &
1 hereby affirm that I am licensed under the provisions of Chapter 9 INSTALL GAF GRAND CANYON CLASS A
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I herebyaffirm under penally of perjury one of the following two declarations:
I have and will maintain a cenilicate 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 whichthis permit is issued. Sq.Ft Floor Area: Valuation:$6500
1 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 APN Number:31639004.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION h'
[certify that I have read this application and suite that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against Iiabil ities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Dale r� All tools shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-BUILDER DECLARATION
Signature of ApplicuhC Date: / L—
I hereby affirm That 1 am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BF.CLASS"A"OR BETTER
I,as owner of the property,or my enployces with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(See 7044.Business&Professions Code). 1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safely Code,Sections 25505,25533.and 25534. ]will
I hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Cade.Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(x)should 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self-insurc for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation.as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
1 have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safely Code,Sectio 5505 5$ }hand 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent: Date:
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person many manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGF.NCV
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state 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
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18,
Signature Date
CITY OF CUPERTINO
3 ITEMS OF 9 PERMIT RECEIPT OPERATOR: SylviaM
COPY # 1
Sec: T ,P:l Rng: Sub: Blk: Lot :
APN . . . . . . . . : 31639004 .00
DATE ISSUED. . . . . . . : 05/11/2012
RECEIPT #. . . . . . . . . : BS000016789
REFERENCE ID # . . . : 12050106
SITE ADDRESS . . . . . : 20205 NORTHGLEN SQ
SUBDIVISION . . . . . . .
CITY. . . . . . . . . . . . . . CUPERTINO
IMPACT AREA . . . . . . .
OWNER STEPHANIE LU
ADDRESS . . . . . . . . . . : 20205 NORTHGLEN SQ
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : FOUR SEASONS
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
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
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REROOP PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT" • BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO,CA 95014-3255
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