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12070247 CITY OF CUPERTINO 13UILDING PI:RMIT IS1111.0 ING ADI)ItESS: 10135 SWAN OAK LN C,ON'I'It,\CI'Olt:I'1 I'IiItSI:N-DGAN INC PERMIT'NO: 12_0702,17 OWN E'RS NA3I E: DINESIi S ANJALI GOL'I. 7980 EN"IT:RPHISE DR DATE ISSUED:07/3012012 OWNER'S PHONE: 4089969026 NEWARK.C\ 94560 11110\ENO;(510)494-9982 LICENSED C0N-I'RAMOR'SDECLARATION r r r BUILDING PERMIT INFO: BLDG ELECT PLUMB - License Class � Lic.# ��/1 7 AI I?CII r RESIDENTIAL r COMM ERCLV.r Contractor�l'-1=o JC/lX;l61110 I7utc 7��0�/ C I herebv al'lirm that l am licensed under the provisions of Chapter 9 •1013 DESCRI PRION: R17NIOVI:WOOD SI IAKI7 AND INSTALL I I SQS (commenting with Section 70111)mf Division 3 of the Business& Professions I'RI:SIDIiNI'IAI- Code and that my license is in fall force and effect. SIIINGI.I:S OVER I2 RADIANT PLYWOOD 309 PELT hercby:ffirm under penalty of perjury one of the following nvo declarations: I have and will maintain a cetaif¢ate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for lire 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. Fl Floor Area: Valuation:56357 permit is issued, APPLICANT CER'I'IFICVI'IOS AI'N Number:3,1232 135.00 Occupancv'1')pe: I cenify that I have read this application and state that lire above inibrmation is correct. I agree to comply with all city and county ordinances and save Isms relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned properly for inspection purposes. (We)agree to save PLRA'II I E\PIRLS IN WORK IS NOTSTARTED ED indemnify and keep harmless the City nl'Cupertino against liabilities,Judgments, costs,and expenses which mayaccmeagainst said City ill consequence critic WITHIN 180 DAYS OF III,RMIT ISSUANCE, OR granting of this permit. Additionally,the applicant understands and will comply INSPECTION. with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAIS FROM LASTCALLI'D INSI ECTION. 9.18. Sighathrc ,� 3�j-(Z Issued I-: Ualr�`3o2/Z D:nc ❑ OWNER-IMILD1?R DI.CLARA'1'ION I hereby atlinn that I am rwempt from the Contractor's License Low for ane of All roofs Shall be inspected prior to any roofing material being installed.If a roof is rhe following Ion reasons: installed without first obtaining an i spection,I agree to remove all new materials for I,as owner of the property,or my employees with wages as their sole compensation, in, will do the work,and the structure is not intended or offered for sale(Sec.7044. /I Business R Professions Code) ='hart of Ap licant: Y�iIZ Date: I,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044.Business l Professions Code), ALL R00F COVERINGS TO ISE..CLASS"A"Oil BEI-IT H 1 hereby affirm under penalty of perjury one of lire following three declarations: I hive and will maintain a Certificate of Conscnt to self-insure for Worker's I h\%,\ItDOIIS MA'llCItIA E,S UISCLOSIiIth; Compensation,as provided for by Section 3700 of the labor Code,lin the I hart read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California I Icalth\S:fen.Code.Sections 25505.25533,and 25534. 1 will maintain I have and will maintain Worker's Compensation Insurmce,as provided for by compliance with the Cupertino Municipal Code.Chapter 9.12 and the Health Section 3700 of the Labor Code,for Lite performance of the work for which Ill Safety Cudc,Section 25532(x)Should I store lir handle hazardous material. Additionally,should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined by the Bay Arca Air Qualirp Management District I will I certify that in the performance of the work for which this permit is issued,I shall maintain cont plin lice with the Culler[inn Municipal Cudc Chapter 9.12 and lite not employ:illy person in any manner so as to become subject to the Worker's ilcalrh R Safely Cudc,Sections 25505.25533,and 25534. Conmpatsalion Imes of California. If,alley making this certiliente of exemption,I become subject to the Worker's Compensation provisions oflhe Labor Code.I must Ow tic' ' rued agenC 3� / forthwith comply with such provisions or this permit Shall be devoted revoked. Dare_ CONS'1'R11C1'ION 1.1';8 UIN'G AGI?NC\' AI'I'IJC\NI'CP;It'1'I PIG\'1'IUN I certify than I have read this application:aid stale that the above infornmation is I hereby affirm that there is n construction lending agency for the performance o1'work's correct. I agree to comply with all city and county ordinances mid state laws relaloo, for which this permit is issued(Sec.3097,Civ C.) to building construction,and hereby authorize representatives of this city to enter Lender's:Ntune 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 acerae against said City in consequence of the granting of'this permit.Additionally,lite applicant understands and will comply ,\ItCI I I'1'CCI"5 UIiCLUtX PION with all non-point source regulations per the Cupertino Municipal Code.Section 9.18. 1 understand my plans shall be used as public records. Signature Doc Licensed Professional CITY OF CUPERTINO FEE ESTIMATOR — BUILDING DIVISION :21 ADDRESS: &,j, L, DATE: 07/30/2012 REVIEWED BY: bobs. APN: BP#: 'VALUATION: $6,357 •PERMITTYPE: Building Permit PLAN CHECK TN'PE: Alteration / Repair PR1111ARY SFD or Duplex PENTAIIIATION 1SFDWLR00 USE: pPERITTYPE: i M WORK tear off wood shake and install comp shingles. SCOPE .. Mech.Plan Check Plrmrb.Plan Cheek Flee.Plan Check r1•lech.Permit Fee: Plumb. Permit Fec: Elec. Permit Fee: Other,tlech.Insp. Ober Plumb Insp. Li I Other Eler.bup. ilach.hup. Fee: Plumb. Insp.Fee: Eler. Insp.Fee: NOTE: This estimate does not inchtdejees tlue to other Departments(i.e. Planning, Public li�orks, Fire,Sanitary Server District,School District, eta). These fees are based on the prelindna. information available and are ontr an evib ate. Contact the Dem or athlu'I into. FEE ITEMS (Fee Resolution 11-053 Eff 7/1/!11 FEE QTY/FEE I MISC ITEMS Plan Check Fee: $0.00 1,100 s.f. Re roof Suppl. PC Fee: Q Reg. Q OT 0.0 1 hrs $0.00 $165.00 IREROOFREs PME Plan Check: $0.00 Permit Fee: $0.00 Suppl. Insp. Fee-.0 Reg. Q OT 0.0 1 hrs $0.00 PME Unit Fee: $0.00 PME Permit Fee: $0.00 COMIMCtion Tax: Adinlnistrotive Fee: O Work Without Permit? 0 Yes t) No $0.00 Advanced Planning Fee: $0.00 Select a Non-Residential Trcmel Documenmtion Fees: Building or Structure Strong Motion Fee: IBSEISAIICR $0.64 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 `SUBTOT ILS: $1.64 $165.00 'TOTAL FEE $166.64 Revised: 07/01/2012 REROOF PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255 CUPERTINO (408)777-3228 • FAX (408)777-3333 •buildinG(alcugertino.org n �7 PROJECT ADDRES" crgqq��.`��' Q� APNN WNAM" ONER NAM`•(.�• ily-41) �' �11 PHONE !=90 Z/' �{ E-MAIL ✓ STREET ADDRESS) SG. ✓\. CITY,STATE/ZIPP / FAX CONTACT NAME Pyo _ 216-57 Z E-MAIL STREET ADDRESS 7n(5 �� Itir Q CI Y.STATE, ZP ^e"� 6(n FAX ❑OWNER ❑ OWNER.aUI1DER ❑ OWNER AGENT .TJ CONTRACTOR ❑CONTRACTORAGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT CONTRACT R AME LICENSEbsLICENSCE, � FILA.LIC.N/Yo0v�ef'S0A eaA1 Jz VT COMPANY NAME E-MAIL FAX STREET ADDRESS L-icsCITY,STATE ZIP PHONE5 7 Si0I- � Isc br- ,tie 'WIRP 5 560 . 0-�/Y ARCHITECT/ENGTNEER NAME LICENSE NUMBER BUS.LIC.N - COMPANY NAME E-MAIL FAX STREET ADDRESS CITY.STATE.ZIP PHONE USE OF ❑ SFDorDuplex Multi-Family ROOFARE/A: VALUATION O 71 STRUCTURE: ❑ Commercial /Of �/ 13,5 Zr EXISTING ROOF TYPE: ❑BUILT-UPROOF ❑ASPHALT SHINGLES WOOD SHAKES ❑WOODSHINGLES ❑OTTER(SPECIFY) REMOVE/REPLACE;LVES IF NO. PLYW000 �'A" ❑ PLYWD `/D OSB PITCH: ROOF ❑NO Y LAYERS THICKNESS' ❑ SA- TYPE' ❑ CDX '12 CUSS' A ICCREPORT 9 PROPOSED ROOF TYPE: ❑BUILT-UPROOF ASPHALT SHINGLES ❑WOOD SHAKES ❑WOODSHINGLES ❑OTHER 13?q DESCRIPTION OF WORK: RerlfUVG SN(lul er Z Dy my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. 1 have read this application and the mfonmmion I have procd is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local ordinances and slate laws relf ating to byi1 it co vection. authorize representatives of Cupertino to enter the about-identified property for inspection purposes. Signature of Applie,mMt;ent: / Date: -?— 3 'z- SUPPLEMENTAL INFORMATION REQUIRED OFFICE use ONLY - _If building is associated with a Home O\vner's Association,provide letter PLAN'`CHECK I-N PE`="�' J=' '' """ •'• RounNG SUP of a royal from HOA. raI pP IJ 01—ER-TIIE-COUNTER.¢. •� BUILDING PIAN REVIEW Provide Planning approval to verify If there any restrictions. PEXPRESS LANIN'N ' L'AN- REVIEwA. Provide copy Of ManufactUrer's Installation Spccillcations. ❑ STANDARD"' '❑ FI.PIRE DEPT .._.. ...._. .._.. ..-... _.. .__.........1..__........_..-.._....�.,..- ovide signed copy of Cupertino's Tear-Off Policy. ❑ OTHER: ReroojApp_201 l.doc revised 03116/1l