12080001 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 6092 WILLOW GROVE LN CONTRACTOR:COSMOS ROOFING PERMIINO: 12080001
O\\'NER'S NAM Ii: JACK TANG&EDITH ONG 999 COMM EIRCIAL 91'911' 10.5 DATE ISSUED:08/0 1 20 1 2
OWNER'S 11II0NE: 4086465767 PALO ALTO,CA 94303 PIIONE NO:(650)969-7663
IW LICENSED CON'1'RACI'OR''7S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class C3 9 Lie.4 29 �' / L4
y / r r r
DIECII RESIDENTIAL COMMERCIALContractor 1 DateL/�Z_
hereby affirm that I am licensed under t provisions of Chapter 9 JOB DESCRIPTION:TEAR OFF EXISTING TAR AND GRAVEL.INSTALL NEW 4
(commencing%,i(h Section 7000)of Division 3 of the Business S Professions PLY
Code and that my license is in full force and effect. CAPSHEET SYSTEM CLASS A 24 SOFT
1 hereby aDirnt trader penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to sell=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 perl'ornmice of de work for which this Sq, Ft Floor Area: Valuation:$1 1115
permit is issued.
AI'1'LICA,NI'CISR'I'IF'IC,CI'I0N APN Number:37538018.00 Occupancy Type:
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 state Imus 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 liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
graining ofthis permit. Additionally,theapplicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupenin unicipal Cade,Section
9.18. `
Issued b}': %EsRr✓ �"/�/� Date:
,.,Signal
D:ni ti
❑ O\\'NF,It-1111LDIiR DF:CL,\R,\'PION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Lim for one of All roofs shall be inspected prior to any roofing material behi;installed Will roof is
the following boo 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 is their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sce.7044,
Business S.Professions Code) Signature of Applicata Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business K Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BE'I TER
I hereby affirm under penalty of perjure one of the fnllowing three
declarations:
I have and will maintain a Certificate of Consent to self insure for Worker's HAZARDOUS BL\T'F:RIAIS DISCLOSURE
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 I lealth&Safety Code.Sections 25505,25533.and 25534. I will maintain
I have and%rill maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the I lealth S
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(x)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 Dtanagement District I 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 Imes ofCaliflmia. If,after making this certificate ofexemption,1
become subject to the Worker's Compensation provisions of the Labor Code,I must Ownerrmlutrixed agci
forthwith comply with such provisions or this permit shall be deemed revoked. (late'
i
ONSITtl1C1'ION LIiNDING,\CF:\Cl'
\I'I'LIC,\\I'CF:K'I'IFIG\"('ION
I certify that I have read this application and state that the above information is I her amt that there is a construction lending agency for the perfomtance of work's
correct.I agree to comply with all city and county ordinances mid state Imes relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,mid 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 theCity 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 ARCIII E171"S DECLARATION
with all non-point source regulation per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
2 ADDRESS: 6092 Willowgrove Lane DATE: 08/01/2012 REVIEWED BY: Sean
APN: BP#: 'VAUATION: $11,115
*PERMITTYPE: Minor Building Permit PLANCIIECKTYPE: Re-roof
PRIMARY PENTANIATION
USE: SFD or Duplex PERMITTYPE: 1SFDWLR00
WORK Tear off existing tar and gravel. Install new 4-ply ca sheets stem.
SCOPE
FEEID ROOFAREA
(S.f.)
1REROOFFRES 2,400
Meeh. Plan Check Plumb. Plan Check Elec. Plat Check
,Meeh. PeraNt Fee: Plumb. Permit Fee: Elec.Permit Fee:
Other Mech.lmvp. Other Plumb Insp. Ll I Other Elce.Lisp.
11•1ech.My.Fee: Plumb. toys. Fee: F.lec.hrsp.Fe:
NOTE: This estinmte does not include fees due to other Departments(i.e. Planning, Public Works, Fire,Sanitary Server District,School
District.etc.). Thesefees are based air the prelitninan information available and are onb,an estinrnte. Contact the Dept for athlt'I info.
FEE ITEMS (Fee Resolution 11-053 E0: 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee:
suppl. PC Fee
Phrm b./A,lecft./Elec
Pennit Fee: $360.00
Suppl. /nsp Fee
Phtub.AAdech.lEec
Plumb./A•lech./Elec Permit Feet'
Construction Tar:
Adtniaisn'ative Fee:
Work Without Permit? O Yes (j) No $0.00
Advanced Planning Fees:
T ryvel Documentation Fees:
Strong Motion Fee: IBSEIS,MICR $1.11 Select an Administrative Item
131(1g Stds Commission Fee: IBCBSC $1.00
SUBTOTALS: $362.11 $0.001 TOTAL FEE: $362.11
Revised: 07/01/2012
1 2" C) oo � l
LEEREROOF PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228• FAX(408)777-3333• buildina(ftuoertino.orcl
PROJECT ADDRESS L Ol 1 1 1o0G�Jc LAl ' APhA rl y7 / I
OWNER NAME C%( 7/ OW I/ PHOYE I •/E-MAIL
I :,JG dog-6Lf6 . 5767
ST �ETOADDZ S W I I I ow 6p-V✓t CIT , STATE,ZIP FAX
L.�/ • �v �p2�,,,Jo c .t . 9 Sol -1
CONTACT NAME WANDA ® COSMOS ROOFING PHONE650-969-7663 E-MAIL
S'IREET'ADDRESS 999 COMMERCIAL STREET 4105 CITY.STATE ZIP PALO ALTO, CA 94303 FAX 650-485-2314
❑OWNER ❑ OWNER-BUILDER ❑ OWNERAGENT ® CONTACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSENUMBER LICENSETYPE BUS.LIC.-
RICH COSMOS 785441 C39
COMPANYNAME COSMOS ROOFING E-MAIL FAX 650-485-2314
STREET ADDRESS 999 COMMERCIAL STREET 4105 CITY.STATE.ZIP PALO ALTO, CA 94303 PHONE 650-969-7663
ARCHITECDE.NGINEER NAME LICENSE NUMBER BUS.LIC-
CONIPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STA1 H.ZIP PHONE;
USE:OF ❑ SFD or Duplex ❑ Multi-Family ROOFAREA: VALUATION
STRUCTURE: ® Commercial (� 1� _# I I , 15
EXISTING ROOF TYPE: ❑BUILT-UPROOT ❑ASPHALTSHINGLES ❑WOODSHAKES ❑WOODSHINGLES ) OTHER(SPECIFY) 62AJC7—
REMOVEIREPLACE RS YES IF NO. PLYWOOD ❑ 'A- Cl PLYWD ❑ OSB PITCH: 'Z/' ROOF
❑ N a LAl'F.R THICKNESS' ❑ SJ8- TYP
DS 7 '1 LASS
fr 11r
A
PROPOSED ROOF TYPE: .BUILT-UPROOT ❑ASPHALTSHINGLES ❑WOODSIIAKIS ❑WOOD SHINGLES El OTHER ICC-ES REPORT-
DESCRIPTION OF WORK:
7e?fR vC-F Tm'z L- (5 Rn✓rZ . ,Jo (2-05r4r-E-'7. I.Js-U-zc. nJc-z,/
L4 - P1� e ±psric�-T. G If4-zs A . z L4 s�i ��,- 3
.
By my signature below,I certify to each orthe following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of W rk and,crify it is accurate. I agree to comply with all applicable local
ordinances and State laws relating to building c I authorize re upertino to enter the above-identified roperty for inspection purposes.
Signature of Applicant/Agent: Date: � Z
SUPPLEMENTALIN MAT - [RED OFFICE USE ONLY
T
_ If building is associated wit a come Owner's Association,provide letter PLANCHECKTYPE Run TING SLIP
of approval from HOA. 1 0Vr.R-niE-CpuN-reR BUILDING-.PLAN REVIEW
_ Provide Planning approval to verify if there any restrictions. tEXPRE.SS ❑ PLAN;NING PIAN REVIEW
_Provide copy or Manufacturer's Installation Specifications. ❑ S"I'ANDARD ❑ FIREDEFF
Provide signed copy of Cupertino's Tear-Off Policy. ❑ orueR:
ReroofApp_2011.dce revised 03/16//1