12090114 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 20656GARDENSIDECIR IX)\'TRACTOR:BRADSHAW ROOFING PERMIT NO: 12090114
INC
OWNER'S NAME: SENTHI SIVARAJ 1821 S BASCOM AVF,PMB 160 IIATF ISSUED:09/13/2012
OWNER'S PI IONS: 4083091256 CAMPBELL,CA 95008 PHONE NO:(408)246-9930
al LICENSED CONTRACI'OR'S DECLARATION JOR DESCRIPTION: RF,SIDFNTIAL C1 COMMERCIAL
License Class C Lic.9 O RE-ROOF 12 SQ-TEAR OFF EXISTING, INSTALL NEW
Contmcto c..J Date II 3 Z ASPHALT SHINGLES CLASS A
hereby affirm that 1 am licensed under the provisions of Chapter')
(commencing with Section 7000)of Division 3 of the Business& Professions
Code and that my license is in full force and effect.
1 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 die Labor Code,for the
performance of the work for whichthis permit is issued. Sq.Ft Floor Area: Valuation:$6000
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for die performance of the work for which this
,\I'N Number:36232017.00 Occupancy"Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state 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 liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the ipplicam understands and will comply Issued by: Date: /
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature V✓ r Date / �� All roofs shall be inspected prior to tiny roofing material being installed.If a roof is
installed without first obtaining an in pection,I agree to remove all new materials for
inspection. ///'''
❑ OWNER-BUILDER DECLARATION /' /1
Signature of Applicant: Date:
1 hereby affirm that I nm exemptfrom the Contractor's License Law formic of
the following two reasons: AL1,ROOF COVF,RINGS TO BE CLASS"A"OR RETIT11
I,as owner of the property,or my errployccs with wages as their sole compensation,
will do the work,aid the structureis not intended or offered for sale(Sce.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to DA-LARDOUS DLATERIAIS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth&Safety Code.Sections 25505,25533,and 25534. 1 will
1 hereby affirm under penally of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safely Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section3700 of die Labor Code,for the air contaminants as defined by the Bay Area Air Qualily Management District
performance of the work for whichthis permit is issued. will maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Ilealth&Safety Code,Sect' as 25505, 5533 id 25534',
Section 3700 of the Labor Code,for die performance of the work for which this 13
permit is issued. Owner or authorized agent: Dntr.
I certify that in the performance of the work for which this permit is issued,I shall
not employ any person inany manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING,AGENCY
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. w'ork's for which this permit is issued(Sec.3097,Civ Q
Lender's Name
APPLICANI'CERTIFICA"rION 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 state 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 ,ARCIII'I'FCf"S DF CLA R,A'I'ION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
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
PIEROOF PERMIT APPUCATIO 1
COMMUNITY DEVELOPILIENT DEPARTMENT- BUILDING DIVISION
10300 TORRE AVENUE •CUPERTINO.CA 95014-3255 v \ -
C U PE RT I N O (408)777-3228 •FAA(408)777-3333•buildinO0cuoertino.orcl
PROIECf ADDRESS O/ C/ r� 1 -- .iPN e
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OWNERNANIE PHON E-SUM�
1
STREET ADDRESS , CIT', STATE,"PI FAX
CONTACT NAME PHONE E.NLAIL
STREETADDRESS I CITY,STATE.ZIP FAX
❑OtVNER ❑ OWNER.BI.TLDER ❑ OwNER AGFM CONiR.ACrOR ❑CONTRACTOR AGENT ❑ ARCHRECT ❑EN(aNEER ❑ DE`IELOPE4 ❑IQtAM
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LICENSE NIIMBE4 LICEISE TPE BUS.LIC.
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COMPANY NAAM E-0LA ` nC
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STREET.ADDRESSC(TT,STATE IP PHONE
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ARCHRELUENOINEERNAME LICENSE NUMBER BUS.LIC.s
CONVANYNAME E-NIAIL FAX
STREET ADDRESS CRT,STATE,ZIP PHONE
USE OF ❑ SFD or Duplex ❑ Multi-Family, ROOF.AREA: VAL36N: a
STRUCTURE. ❑ L'onunercial 1
EXISTMU-ROOFTYPE: ❑BUILT{PROOF ❑ASPH,LLTSHMGLES m/ �N1'
WOODSHAKES WOOOSKINGLES ❑OTHER(SPECPY)
REMOVE REPLACE 94FS IF NO. PLY::700 :5 ❑ PLYWD ❑ PITCH: ROOF
- RJTHICKNESS ❑ 2A❑ Nn .X
A
WIPOSED ROOF TYPE: ❑BUILT-UP rOOF ASPH,ALTSHniGLES ❑WOOD SHAKES ❑WOOD SHINGLES ❑OTHER ICC-ES REPORT s
DESCRIPTION OF WO RK: _
-L `C c
By my signature below.f cerity to each of the iollo%ing: I am die propertyowner 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 Itc Description of Tvork and verify itis accurate. l agree to:.amply with all applicable loci
ordinances and stare laws relating t buit in con , on. IM riz 'representatives of Cupertino to enter the above-idendfi:d property for inspection purposes.
SignmureofAppticant/Agent: l'� _ Date:
SUPPLEMENT.-IL INFORNLaTION REQUIRED OFFICE use ONLY
If building is associated With a Home OWnerS ASSOCiadOB,provide letter PLAYCHECK TYPE ROITITNG SLIP
of approval from HOA. -TTHX-COUNTER BUR.DMc PUN REVIEW
_Provide Planning approval tO VeliN if there any restrictions. ❑ EXPRESS ❑ PI- wp;r PLAY arVirw
_Prod a COPY of Nfanufmcmrer S Installation Specifications. ❑ STANDARD ❑ FIRE DEPT
Mwde signed copy of Cupertino's Tear-Off Policy. ❑ OTHER:
Reroo&p_201 Ldoe ravirad 03/12.11
CITY OF CUPERTIN.O
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS:2e�S� gardenside circle DATE: 0 911 2/2 0 1 2 REVIEIVED BY: bobs.
APNi BP#: 'VALUATION: $6,000
*PERMIT TYPE: Building Permit PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or Duplex PENTAMATION 1SFDWLR00F
USE: PERMITTYPE: A
WORK remove existing roof. Install new asphalt shingles 1200 s.f.
SCOPE
Xlech. Plan Check Plumb.Plan Check Flee.Plan Check
blech. Permil Fee: Plumb.Permit Fee: flee. Penni!Fee:
Other,llech. Insp. 01her Plumb Insp, Other Eler.Insp.
Me&Insp. Fee: Plumb. hip. Fee: Elec.Insp.Fee:
NOTE: This estimate does not include jeer due to other Departments(i.e. Planning,Public Works, Fire,Sanitary Server District,School
District, etc). These fees are based on the prelinzinan information mailable and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (Fee Resolution 11-053 FIL 7/1/11) FEE QTY/FEE MISC ITEMS
Plan Check Fee: $0.00 = .f. Re-roof
Suppl. PC Fee: Q Reg. () OT 0.0 Thrs $0.00 $180.00 /REROOFRES
PME Plan Check: $0.00
Permit Fee: $0.00
Suppl. Insp. Fee.0 Reg. Q OT 0,0 firs $0.00
PME Unit Fee: $0.00
PME Permit Fee: $0.00
Consnvction Tar:
Administrative Fee:
Work Without Permit? O Yes (F) No $0.00
Advanced Planning Fee: $0.00 Select a Non-Residential
Tnn-el Documentation Fees: Building or Structure 0
A
Strong Motion Fee: IBSEISMICR $0.60 Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC $1.00
sUBTOT AEsh $1.60 $180.00 t ,TOTaEFEE:;j $181.60
Revised: 07/0112012